An elderly client is brought to the emergency department with lethargy, chills, and sharp chest pain with deep breathing. Pulse oximeter shows 93% on room air and respirations are 24/min. What is the nurse's initial action? A)Administer intravenous (IV) morphine B)Auscultate the client's lung sounds C)Initiate an IV infusion of normal saline D)Initiate nasal oxygen at 3 L/min

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Assessment is the first step in the nursing process that is used to gather information. Lung auscultation is the nurse's initial action with this client. Before intervening, the nurse should assess respiratory status and vital signs to obtain the baseline data that will be compared to subsequent changes. (Option A) Morphine is administered to provide comfort and pain relief. This is an appropriate intervention to facilitate breathing and oxygenation, but it is not the best initial action. Assessment of respiratory status and vital signs should be performed before intervening. (Option C) Initiation of an IV infusion of saline is done to provide hydration and IV access. This is an appropriate intervention, but it is not the best initial action. (Option D) Although the saturation is decreased (93%) and the respiratory rate is increased (24/min), both are adequate to support oxygenation at this time. Nasal oxygen at 3 L/min should be initiated to improve oxygenation. Even though this is an appropriate intervention, it is not the best initial action. Educational objective: The nurse should first assess the client's condition before intervening. This is important as the ability to plan effective nursing care, set priorities, identify appropriate interventions, and make sound clinical decisions is based on the information obtained from the assessment.

An Elderly Client Is Brought to the Emergency Department with Lethargy