Question

When using the airway, breathing, circulation approach to client care, the nurse should identify decreased oxygen saturation as the priority finding to address and report to the provider. A client who is postoperative following a total laryngectomy is at higher risk for hypoxia because of airway obstruction. A nurse in the emergency department is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first?

A) Apply supplemental oxygen.
B) Administer a painkiller for relief.
C) Perform a routine physical assessment.
D) Initiate nasogastric tube insertion.

Answer 1

The nurse should first apply supplemental oxygen to a client experiencing a pulmonary embolism. This action is prioritized to address immediate life-threatening hypoxia, and it aligns with the airway, breathing, circulation (ABC) approach to client care.

Step-by-step explanation:

When caring for a client experiencing a pulmonary embolism, the first action a nurse should take is to apply supplemental oxygen. This immediate intervention is crucial because a pulmonary embolism can lead to hypoxia, which requires prompt assessment and enhancement of oxygen supply to the tissues. Applying supplemental oxygen can help improve the patient's oxygen saturation levels and stabilize their condition while further interventions are being prepared. Following the airway, breathing, circulation (ABC) approach, the nurse ensures the airway is open, addresses breathing needs with supplemental oxygen, and monitors circulation, streamlining care to prioritize life-sustaining measures first.

Once oxygen is provided, it's essential for the nurse to notify the medical provider, continue with assessing patient vitals, and follow through with additional prescribed treatments. Administering painkillers and other interventions like initiating a nasogastric tube insertion may come later, after addressing the immediate life-threatening condition of a compromised airway and the need for oxygen.