A nurse enters the room of a client with chronic obstructive pulmonary disease (COPD) and observes that the client is experiencing acute shortness of breath, using accessory muscles to breathe, and appears highly anxious. Order the following nursing interventions from highest priority (first action) to lowest priority (last action).
- 1Elevate the head of the bed to a high-Fowler's position.
- 2Assess the client's vital signs and oxygen saturation.
- 3Administer the prescribed PRN supplemental oxygen.
- 4Notify the healthcare provider of the client's condition.
Answer
The correct sequence of actions is: Elevate the head of the bed, assess vital signs and oxygen saturation, administer prescribed oxygen, and finally notify the healthcare provider.
Prioritization in an acute respiratory emergency relies on the Airway-Breathing-Circulation (ABC) framework and the nursing process. Elevating the head of the bed is the fastest, most effective independent action to immediately improve breathing mechanics (Airway/Breathing). Next, the nurse assesses the client (oxygen saturation, vital signs) to determine severity and guide the next steps. After assessment, the nurse implements targeted interventions like administering prescribed oxygen. Finally, once the client is stabilized and clinical data is collected, the nurse notifies the healthcare provider to report the event and obtain any necessary further medical orders.
Step-by-Step Solution
Key Concept
In acute respiratory distress, the nurse prioritizes immediate, independent airway interventions (positioning) first, followed by rapid assessment, targeted implementation of treatments, and finally provider notification.