A patient with acute respiratory failure is receiving oxygen by mask. The patient is restless, cyanosed around the lips and has an ineffective cough. Which nursing action has the highest priority?
Correct answer: A. Assess airway patency and call for urgent assistance
- A. Assess airway patency and call for urgent assistance
- B. Offer oral fluids to loosen the secretions
- C. Place the patient in a flat supine position
- D. Document the findings and reassess in one hour
Explanation
Cyanosis, ineffective cough and restlessness indicate severe oxygenation or ventilation compromise. Airway and breathing take priority, so the nurse should assess patency, summon help and prepare for urgent airway support rather than delay care.
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About Respiratory Nursing
Covers nursing assessment and management of asthma, chronic obstructive pulmonary disease, pneumonia, tuberculosis, pleural disorders and respiratory failure. Key areas include breath sounds, oxygen therapy, airway suctioning, inhaled medicines, arterial blood gases and the difference between hypoxia, hypoxemia and carbon dioxide retention.
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