Question

The nurse is admitting to the medical-surgical unit an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure. The patient is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take?

1) Review and implement the primary care provider's prescriptions for treatments.
2) Perform a quick physical examination of breathing, circulation, and oxygenation.
3) Gather a thorough medical history, including current symptoms, from the family.
4) Administer oxygen to the patient through a nasal cannula.

Answer 1

A nurse should first perform a quick physical examination to assess breathing, circulation, and oxygenation in a patient showing acute respiratory distress.

Step-by-step explanation:

The first action a nurse should take when admitting an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure who is complaining of shortness of breath is to perform a quick physical examination of breathing, circulation, and oxygenation. This is critical to assess the patient's immediate needs and to determine the severity of their shortness of breath, which could necessitate emergency interventions such as the administration of oxygen. In this scenario, the patient's symptoms and their potential danger take precedence over collecting a medical history or reviewing orders, which although important, can be addressed immediately after ensuring the patient's stability.