Question

A client is admitted to the ICU following an open reduction and internal fixation of the right femur. The client is suddenly agitated and reports chest pain and SOB. Petechiae are present over the chest. Which action should the nurse perform immediately? A. Obtain pulse ox reading B. Administer oxygen via facemask C. Give methylprednisolone IV D. Request therapist to provide an albuterol aerosol"

Answer 1

Based on the symptoms and findings you've described, the immediate action the nurse should take in this situation is to administer oxygen via a facemask (Option B). The client's sudden agitation, chest pain, and shortness of breath indicate a potential respiratory distress or compromise.

Administering oxygen will help improve oxygenation and alleviate the symptoms. It is crucial to prioritize oxygenation and ensure the client receives an adequate oxygen supply to prevent further complications.

After providing oxygen, the nurse should continue to assess the client's condition, monitor vital signs, and notify the healthcare provider about the new onset of symptoms. This will ensure appropriate further interventions are initiated based on the client's condition.

It is important to note that the other options mentioned (obtaining a pulse ox reading, giving methylprednisolone IV, and requesting albuterol aerosol) may be appropriate interventions but are not the immediate priority in this situation. The focus should be on providing oxygen to address the client's respiratory distress.