A patient who had abdominal surgery has sudden shortness of breath, sharp chest pain, and a heart rate of 132 per minute. Oxygen saturation is falling. What should the nurse do first?
Correct answer: B. Place the patient in a suitable position and call for urgent help
- A. Encourage the patient to walk to the bathroom
- B. Place the patient in a suitable position and call for urgent help
- C. Offer oral fluids and reassess the pain
- D. Document the findings before contacting the prescriber
Explanation
The sudden symptoms suggest a potentially life-threatening pulmonary embolism or other acute respiratory problem. Positioning the patient to support breathing and summoning urgent help address immediate airway and breathing concerns.
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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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