The nursing assistant is caring for a postoperative client supine in bed receiving 2 L per nasal cannula who suddenly develops dyspnea, RR 28, HR 110, BP 100/60, T 97°F, and pulse oximeter 88%. What action should the nursing assistant take immediately after notifying the nurse?

Question

Quizplus · Accepted Answer

The client is supine in bed and having shortness of breath, and their pulse oximetry is low, so immediately raising the head of the bed to high Fowlers allows the chest to fully expand. The nursing assistant should then determine whether the oxygen is patent, ask the client to breathe deeply and to cough because as the client lies supine, secretions may pool and smaller airway collapse (atelectasis) may develop. All of these measures may be taken as the nurse is coming to assess and help the client. The nursing assistant can monitor the pulse oximetry to determine whether the measures are helping because the level should increase, and the client should become less short of breath. Charting is the last action to take.

The Nursing Assistant Is Caring for a Postoperative Client Supine