A patient has noisy breathing, a respiratory rate of 32 breaths per minute and an oxygen saturation of 84%. Which action has the highest priority?
Correct answer: B. Assess and maintain airway patency
- A. Offer fluids to reduce throat dryness
- B. Assess and maintain airway patency
- C. Complete the health history questionnaire
- D. Teach the patient about breathing exercises
Explanation
Airway and breathing take priority because the patient has signs of threatened oxygenation. The nurse should assess and maintain airway patency before teaching, documentation or comfort measures.
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About Nursing Process and Health Assessment
Assessment gathers subjective and objective data through health history, physical examination and observation. The nursing process then uses nursing diagnoses, planning, implementation and evaluation to provide individualised care, while distinguishing a nursing diagnosis from a medical diagnosis and identifying priorities such as airway, breathing, circulation and safety.
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