Question

A nurse is caring for a group of clients on a unit. Which of the following assessment findings should the nurse recognize as the priority to report to the charge nurse?

a) Dry, intact skin
b) Blood pressure within normal range
c) Heart rate slightly above baseline
d) Sudden onset of respiratory distress

Answer 1

The priority for the nurse to report is the sudden onset of respiratory distress, as it indicates a potentially life-threatening condition requiring immediate attention.

Step-by-step explanation:

Among the assessment findings presented, the nurse should recognize the sudden onset of respiratory distress as the priority to report to the charge nurse. This symptom indicates a potentially life-threatening situation that requires immediate intervention. It can be indicative of conditions such as asthma, pneumonia, pulmonary embolism, or heart failure. A rapid response is crucial for the stabilization and appropriate management of the patient's breathing and oxygenation status. When comparing the other options, which include dry, intact skin, blood pressure within normal range and heart rate slightly above baseline, these do not reflect the same level of immediate risk to the patient's health.