Question

An elderly client is brought to the emergency department. Vital signs are: Temp: 102 degrees F; P: 88; R: 32; BP: 160/86. Upon physical examination, the client is having difficulty breathing. Which of the following would be most appropriate for the nurse to do next?

a. Instruct the client to take slow, deep breaths
b. suction the client's pharynx of secretions
c. apply a pulse oximeter to the client's finger
d. help the client perform postural drainage

Answer 1

The most appropriate action for the nurse is to apply a pulse oximeter to the client's finger to assess oxygen saturation levels before proceeding with any further interventions. the correct answer is C.

Step-by-step explanation:

The most appropriate next step for the nurse would be to apply a pulse oximeter to the client's finger. This non-invasive tool will quickly provide data on the oxygen saturation level in the client's blood, which is crucial given the observed difficulty in breathing and the potential risk of hypoxemia. While the other options may also be important, the immediate priority is to assess the severity of the client's respiratory status.

Deep breaths may not be helpful if the client is unable to effectively oxygenate their blood, and postural drainage and suctioning are typically not first-line assessments. Once the oxygen saturation level is known, additional interventions can be planned to address the client's respiratory distress appropriately. This might eventually involve suctioning airway secretions or helping the client with postural drainage if indicated, but first, obtaining a pulse oximetry reading is crucial for guiding these decisions.