Fundamentals of Nursing Q 403
Nurse CJ is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse’s priority?
A. Increase the oxygen flow.
B. Assist the client with Fowler's position.
C. Promote removal of pulmonary secretions.
D. Attain a specimen for arterial blood gases.
Correct Answer: B. Assist the client with Fowler’s position.
The priority action the nurse should take when using the airway, breathing, circulation approach to care delivery is to relieve the clients’ dyspnea. Fowler’s position facilitates maximal long expansion and thus optimizing breathing. With the client in this position, the nurse can better assess and determine the cause of the clients dyspnea.
Option A: The client may need more oxygen, as hypoxemia may be the cause of his difficulty breathing. However, administering oxygen and adjusting the fraction of inspired oxygen requires the provider’s prescription after a careful assessment of the clients’ oxygenation status, there is a higher priority given the nature of the client’s distress.
Option C: The client may need suction or expectoration, as pulmonary secretions may be the cause of his difficulty breathing. However, there is a higher priority given the nature of the client’s distress.
Option D: It is important to check the client’s oxygenation status, and in many nursing situations, assessment precedes action, but there is a higher priority given the nature of the clients’ distress.