Question

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states, "I am anxious and unable to get enough air." VS are HR 117/min, R 38/min, temperature 101.2f, and BP 100/54 mm Hg. Which of the following nursing actions is the priority?

A. Notify the provider.
B. Administer heparin via IV infusion.
C. Administer O2 therapy.
D. Obtain a CT scan.

Answer 1

C. Administer O2 therapy. The priority nursing action for a client with acute dyspnea and diaphoresis is to administer O2 therapy to address the potential for hypoxemia. Once the patient's oxygenation is supported, the provider should be notified for further assessment and management.

Step-by-step explanation:

The client in question is experiencing acute dyspnea (difficulty breathing), diaphoresis (sweating), anxiety, and an inability to get enough air. With vital signs (VS) indicating a heart rate (HR) of 117/min, respiratory rate (R) of 38/min, temperature of 101.2°F, and blood pressure (BP) of 100/54 mm Hg, it is evident that the client is in immediate distress. The priority action in this case, based on the ABC (Airway, Breathing, Circulation) approach to patient care, is to administer O2 therapy. Ensuring adequate oxygenation is crucial for the patient's survival and should supersede all other actions at this point. Once oxygen therapy is initiated, it is imperative to notify the provider about the client's condition for further assessment and intervention. Other actions, such as administering heparin via IV infusion and obtaining a CT scan, may be necessary but are not the immediate priority given the client's acute presentation with possible hypoxemia and unstable vital signs that suggest a potential life-threatening condition such as sepsis or pulmonary embolism.

The priority nursing action in this scenario is to administer O2 therapy (option C).The client's symptoms of acute dyspnea, diaphoresis, anxiety, and inability to get enough air indicate that the client is experiencing respiratory distress. The vital signs, including increased heart rate, increased respiratory rate, elevated temperature, and hypotension, further support this. Administering O2 therapy can help improve the client's oxygenation and relieve their symptoms of dyspnea. Notifying the provider (option A) is important, but it is not the immediate priority in this situation. Administering heparin via IV infusion (option B) and obtaining a CT scan (option D) are not indicated based on the given information and the client's symptoms.