A nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority?
A) Risk for skin breakdown
B) Impaired gas exchange
C) Activity intolerance
D) Risk for infection

Question

Quizplus · Accepted Answer

The most important nursing intervention is to maintain airway and circulation for this patient; therefore, Impaired gas exchange is the first nursing priority. Activity intolerance is a concern but is not the priority in this case. Risk for skin breakdown and Risk for infection are also important but do not address an immediate impairment with physiologic integrity.

A Nurse Is Caring for a Patient with Left-Sided Hemiparesis