A patient with a respiratory rate of 28 per minute is anxious but has clear speech and an oxygen saturation of 98% on room air. Which assessment is most appropriate next?
Correct answer: A. Assess pain, anxiety and recent activity
- A. Assess pain, anxiety and recent activity
- B. Apply oxygen immediately at a high flow rate
- C. Ask the patient to hold the breath briefly
- D. Document tachypnoea without reassessment
Explanation
Tachypnoea can result from anxiety, pain, fever, activity or respiratory disease, so the nurse should assess likely causes and associated findings. Oxygen is not automatically required when saturation and breathing effectiveness are adequate.
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About Vital Signs and Monitoring
Vital signs include temperature, pulse, respiration, blood pressure, oxygen saturation and pain assessment. Coverage includes correct measurement sites and techniques, normal adult ranges, factors that alter readings, trends in patient observations, and the difference between an abnormal finding that needs reassessment and one requiring immediate reporting.
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