A patient suddenly develops noisy inspiratory breathing, difficulty speaking, and increasing anxiety. What should the nurse do first?
Correct answer: A. Activate emergency assistance and remain with the patient
- A. Activate emergency assistance and remain with the patient
- B. Offer oral fluids and reassess the breathing later
- C. Document the findings before notifying the provider
- D. Place the patient flat and obtain a routine history
Explanation
Stridor and difficulty speaking suggest an acute upper-airway threat. The nurse should activate emergency assistance, stay with the patient, and support airway and breathing while help arrives. Oral fluids, documentation, and a routine history must not delay emergency care.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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