RN Nursing · Airway Management · Practice question
Complete the following sentence by using the lists of options. The nurse should first address the client ____ followed by the client's ____
Emergency Department — Anemia Case Study
Nurses' Notes
1020: Female client presents to emergency department with reports of shortness of breath and fatigue. Client drowsy. Nail beds and mucous membranes dusky. Capillary refill greater than 3 seconds. Clear breath sounds in all lung fields. Client reports smoking one pack of cigarettes per day for 40 years. Client is using pursed lip breathing and has barrel chest. Reports not seeing any blood in urine but has seen blood in stool and had episode of bloody emesis today. Cardiac monitor alarms on. Monitor shows sinus tachycardia.Vital Signs
1030: Temperature 37.2° C (99° F) Heart rate 110/min Respiratory rate 24/min Blood pressure 88/58 mm Hg Oxygen saturation 89% on room airAnswer & explanation
Correct:
The client's oxygen saturation of 89% on room air represents an immediate life-threatening concern — hypoxia requires the highest priority intervention to prevent organ damage and cardiac arrest. After addressing oxygenation, the nurse should address the client's energy levels (fatigue/drowsiness), which reflects the anemia's impact on tissue perfusion. Temperature of 37.2°C is within normal limits and does not require prioritized intervention. This follows the ABC (airway, breathing, circulation) priority framework used in emergency nursing.
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