A nurse enters the room of a client with a history of asthma. The client is using accessory muscles to breathe, has audible wheezing, and an oxygen saturation of 88% on room air. In which order should the nurse perform the following actions? Arrange the actions in order of priority from first to last.
- 1Place the client in a high-Fowler's position.
- 2Apply supplemental oxygen as prescribed.
- 3Administer the prescribed short-acting inhaled bronchodilator.
- 4Reassess the client's respiratory rate and oxygen saturation.
Cevap
The priority sequence is to first maximize lung expansion via positioning, then treat the hypoxemia with oxygen, followed by administering a bronchodilator to relieve the spasm, and finally reassessing the client's response.
The correct sequence prioritizes airway and breathing according to emergency care principles. Elevating the head of the bed is the fastest physical action to improve lung expansion. This is immediately followed by supplemental oxygen to correct the severe hypoxemia. Once the patient is oxygenated, the nurse administers the bronchodilator to treat the underlying bronchospasm. Finally, the nurse reassesses the client to evaluate the effectiveness of these interventions.
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Anahtar Kavram
Prioritization of Care in Acute Respiratory Distress