NCLEX RN Practice Question

The correct answer is to assess oxygen saturation with a pulse oximeter. In a scenario where a client displays signs of respiratory distress, nursing priorities follow the Airway, Breathing, Circulation (ABC) model. Since the client can still speak (indicating a patent airway), assessing the effectiveness of breathing and oxygen delivery through pulse oximetry becomes the priority. This provides objective data to determine the need for oxygen therapy or other interventions.

Other options such as administering oxygen and elevating the head of the bed may be appropriate secondary actions but should follow the assessment of oxygen saturation. Administering oxygen without knowing the saturation level could delay identifying and addressing the underlying issue. Similarly, auscultating lung sounds is a valuable assessment but has lower priority than determining the client’s oxygenation status.