A nurse is caring for a client who is two days postoperative following a right total knee arthroplasty. The client suddenly reports sharp, pleuritic chest pain, severe shortness of breath, and a feeling of impending doom. The client appears diaphoretic and highly agitated. Arrange the following nursing actions in the priority order they should be performed. (Place the first action at the top and the last action at the bottom.)
- 1Elevate the head of the bed to a high-Fowler's position.
- 2Apply high-flow supplemental oxygen via a non-rebreather mask.
- 3Obtain a complete set of vital signs, including oxygen saturation.
- 4Notify the rapid response team and the healthcare provider.
- 5Establish a secondary peripheral intravenous access line.
Cevap
The correct priority sequence is to first elevate the head of the bed, then apply oxygen, obtain vital signs, notify the rapid response team, and finally establish secondary intravenous access.
The correct sequence prioritizes immediate, non-invasive airway and breathing interventions (elevating the head of the bed and applying oxygen) because they take seconds to perform and immediately address the life-threatening hypoxia. Once the client's breathing is mechanically supported, the nurse must assess the client's physiological status (vital signs) to gather the necessary data before communicating with the rapid response team. Finally, preparing for advanced medical interventions (establishing IV access) is done once help is on the way.
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Anahtar Kavram
In an acute respiratory emergency, nursing priorities follow the airway, breathing, circulation (ABC) framework and the nursing process: intervene immediately to support airway/breathing, assess to gather data, communicate findings, and prepare for advanced medical management.