You are assigned to care for Ms. C., an 81-year-old patient who was admitted today with symptoms of increasing shortness of breath over the last week. She is currently receiving oxygen through a nasal cannula at 3 L/min. You go into the room to assess her. You find that she is sitting up in bed at a 60-degree angle. She is restless and her respirations appear labored and rapid. Her skin is pale with circumoral cyanosis. You ask if she feels more short of breath. Because she is unable to catch her breath enough to speak, she nods her head yes. Which action should you take first?
Listen to her breath sounds.
Ask when the shortness of breath started.
Increase her oxygen flow rate to 6 L/min.
Raise the head of the bed from 75 to 85 degrees
Based on knowledge you have learned, you realize the patient's symptoms indicate acute hypoxemia, so improving oxygen delivery is the priority. The other actions also are appropriate, but they are not as critical as the initial action.

Question

Quizplus · Accepted Answer

The Answer is In this scenario, the first action you should take is to listen to Ms. C.'s breath sounds. This immediate assessment will provide crucial information about her respiratory status and help determine the underlying cause of her increased shortness of breath. Breath sounds can reveal the presence of fluid, wheezing, or other abnormalities that may require urgent intervention.
While increasing the oxygen flow rate may seem like an appropriate response to her symptoms of acute hypoxemia, it is essential to assess her breath sounds before making any changes to her oxygen therapy. This is because increasing the oxygen flow rate without proper assessment could potentially lead to oxygen toxicity or worsen underlying conditions such as carbon dioxide retention in patients with chronic obstructive pulmonary disease (COPD).
After assessing her breath sounds, you can then determine the most appropriate next steps, which may include adjusting her oxygen therapy, raising the head of the bed to improve ventilation, or seeking additional medical interventions based on the findings of your assessment.
It is also important to monitor her vital signs, provide reassurance, and stay with her while awaiting further orders from a healthcare provider. If her condition appears to be deteriorating rapidly, you should call for immediate medical assistance.

You Are Assigned to Care for Ms