Question

The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?

Answer 1

The primary action for a nurse when observing a patient with pursed lip breathing is to assess the patient's respiratory status and report findings to ensure proper care and intervention.

Step-by-step explanation:

The most important action for a nurse to implement first when observing a client leaning forward and using pursed lip breathing is to assess the patient's respiratory status. This breathing pattern often indicates that the client is experiencing respiratory distress. The nurse should promptly measure the client's vital signs, including respiratory rate, oxygen saturation, and assess lung sounds. They should also inquire about any additional symptoms such as chest pain or shortness of breath. After completing the assessment, the nurse should report significant findings to the healthcare team and ensure that the appropriate interventions are initiated.

Before administering any medications, the nurse and an anesthesia professional must review aloud the key concerns for the recovery and care of the patient, as stability of vital signs is imperative for safe medication administration. Furthermore, in the context of potential respiratory distress, some medications could exacerbate the situation, therefore the safety of the patient is the foremost priority.