Level: Foundational
Difficulty: Easy
Subtopic: Vital signs
NCLEX: A postoperative client has a respiratory rate of 8/min, shallow breathing, and SpO2 86% on room air. What is the…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A postoperative client has a respiratory rate of 8/min, shallow breathing, and SpO2 86% on room air. What is the nurse's priority action?
Question
A. Assess airway and breathing, provide oxygen per protocol, and notify the provider.
B. Document the findings and recheck vital signs in 4 hours.
C. Administer the scheduled analgesic first to improve breathing effort.
D. Delegate vital sign monitoring to UAP and continue morning care.
B. Document the findings and recheck vital signs in 4 hours.
C. Administer the scheduled analgesic first to improve breathing effort.
D. Delegate vital sign monitoring to UAP and continue morning care.
Rationale
Correct answer: A. Assess airway and breathing, provide oxygen per protocol, and notify the provider.
Rationale: ABCs take priority. Shallow respirations with hypoxemia require immediate airway and breathing intervention.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: ABCs take priority. Shallow respirations with hypoxemia require immediate airway and breathing intervention.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.