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Zorluk: KolayPhysiological Adaptation

A practical nurse is caring for a client with heart failure who is resting supine in bed. The client suddenly becomes restless and reports severe difficulty breathing. In what sequence should the nurse perform the following actions? (Arrange the actions from first to last.)

  1. 1Assist the client into a high-Fowler's position.
  2. 2Obtain the client's vital signs and oxygen saturation.
  3. 3Administer supplemental oxygen as prescribed.
  4. 4Report the change in condition to the charge nurse.

Cevap

The correct sequence is: assist the client into a high-Fowler's position, obtain vital signs and oxygen saturation, administer supplemental oxygen as prescribed, and finally report the change in condition to the charge nurse.
In any acute respiratory distress scenario, anatomical positioning to open the airway and facilitate lung expansion is the absolute first priority (Airway/Breathing). After the airway is physically optimized, the nurse collects necessary data (vital signs and oxygen saturation) to guide further intervention, administers prescribed physical treatments (oxygen), and finally communicates the status change to the broader healthcare team.

Adım Adım Çözüm

1
Identify the immediate threat to the client's stability.
The client is experiencing sudden respiratory distress, making airway and breathing the absolute top priority.
According to the ABCs (Airway, Breathing, Circulation) framework, respiratory compromise must be addressed before other actions.
2
Select the quickest, most direct intervention to improve breathing.
Assisting the client to a high-Fowler's position is chosen as the first action.
Repositioning provides immediate relief for dyspnea by utilizing gravity to pull organs away from the diaphragm, requiring no equipment or orders to initiate.
3
Determine the next priority after optimizing the client's airway.
Obtaining vital signs and oxygen saturation is the second action.
Data collection is necessary to quantify the severity of the distress and guide further clinical decisions within the PN scope of practice.
4
Implement ordered therapies based on the newly collected data.
Administering prescribed supplemental oxygen is the third action.
Oxygen therapy directly treats the underlying hypoxia identified during the assessment phase.
5
Ensure the healthcare team is aware of the acute change.
Reporting to the charge nurse is the final action in this immediate sequence.
Once the client is stabilized and initial interventions are complete, the supervising nurse must be informed for further medical evaluation and potential modification of the care plan.

Anahtar Kavram

Prioritization of airway and breathing management during acute respiratory distress
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Konular

Physiological Adaptation

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