The medical surgical nurse cares for a client who had a mediastinal tumor removed 2 days ago and reports difficulty breathing. The client becomes confused and restless, and respirations are 30/min. What is the nurse's next action?

Question

Quizplus · Accepted Answer

11ecbb05_ca75_a1da_b433_77c6d943bfde_MD0009_00 The rapid response team (RRT) consists of a group of health care providers who bring critical care expertise to the bedside of clients demonstrating early signs of deterioration such as dyspnea, confusion, and restlessness. This team differs from the "Code" team that is called when a client stops breathing or goes into cardiac arrest. Any health care worker can call the RRT. (Option A) The client's restlessness and confusion are likely secondary to low oxygenation. Anxiety will cause hyperventilation, which will only exacerbate the situation. However, administering anti-anxiety medication is not the priority over obtaining help quickly. In addition, the client's oxygenation could deteriorate depending on the prescribed anti-anxiety medication, which could depress respirations. (Option B) The health care provider who performed the surgery must be notified of the client's deteriorating condition; however, this should be done after calling the RRT. Stabilizing the client is the priority. (Option D) The recovery position is used as a first aid measure for an unconscious client who is still breathing. The client is placed on the left or right side in a three-fourths prone position with the top leg flexed. This position maintains the airway and ensures that the client does not choke on vomit. Educational objective: When a client is demonstrating clinical deterioration, the nurse's priority is to prevent full respiratory or cardiac arrest by calling the rapid response team.

The Medical Surgical Nurse Cares for a Client Who Had