A client hospitalized for community-acquired pneumonia suddenly becomes restless and anxious. Assessment findings are: respirations 32/min, heart rate 120/min, blood pressure 136/80 mm Hg, and oxygen saturation 89 % on room air. Which action should the nurse take first?
Encourage the client to cough and deep-breathe to mobilize secretions.
Increase the intravenous normal saline rate to 150 mL/hr.
Apply oxygen at 2 L/min via nasal cannula and reassess oxygen saturation.
Obtain a stat arterial blood gas sample for analysis.
Restlessness, tachypnea, tachycardia, and an SpOâ‚‚ below 90 % are early indicators of hypoxemia. According to the airway-breathing-circulation (ABC) priority framework, the nurse should address breathing problems before other concerns. Applying supplemental oxygen as prescribed increases the fraction of inspired oxygen, improves arterial oxygenation, and can rapidly relieve the client's distress. Obtaining arterial blood gases, encouraging coughing, or increasing IV fluids may be needed later, but they do not correct the critical drop in oxygen saturation as quickly as administering oxygen.
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