Final answer:
The first action a nurse should take is to auscultate the breath sounds in a patient with severe dyspnea and a cough, as this provides immediate and critical information on the patient's respiratory status which is vital for determining subsequent care.
Step-by-step explanation:
Which action should the nurse do first for a patient with severe dyspnea?
In a clinical scenario where a patient is admitted to the emergency department with severe dyspnea and a dry, hacking cough, the priority nursing action would be to auscultate the breath sounds. This is because breathing issues such as dyspnea can indicate severe and life-threatening conditions that need immediate attention. Auscultating the breath sounds can reveal abnormal lung sounds such as crackles or wheezes, which can indicate underlying problems such as pneumonia, pulmonary edema, or exacerbation of chronic heart failure. Immediate assessment of the patient's respiratory status is crucial in guiding subsequent interventions and treatments.
Answers to similar questions about evaluating a patient can include further diagnostic steps such as using a pulse oximeter to measure hypoxemia (low levels of oxygen in the blood), ordering a chest radiograph to look for any abnormalities like a "shadow" in the lungs, or collecting sputum samples for diagnostic evaluation.
Effective diagnostic techniques like auscultating for heart sounds with a stethoscope are crucial in assessing the state of a patient's heart, especially when the patient has a history of cardiovascular issues. Immediate assessment is essential for making timely decisions about patient care and can be a determining factor in the outcome of the treatment.
Learn more about Patient Assessment