The nurse is admitting a client who reports symptoms of dyspnea. The nurse notes edema of the upper arms, face, and neck. What is the nurse's priority assessment?
Degree of upper body vasculature observed.
Arm circumference and degree of edema.
Blood pressure and heart rate.
Peripheral sensation and movement of upper extremities.
The Correct Answer is C
A. Assessing the degree of upper body vasculature may provide some information, but it does not directly address the client's current symptoms or vital status.
B. Measuring arm circumference and evaluating the degree of edema are important for understanding the extent of swelling but do not assess the client’s hemodynamic stability or respiratory status.
C. Blood pressure and heart rate are critical assessments in this scenario, especially considering the client’s dyspnea and upper body edema. Changes in these vital signs can indicate potential respiratory distress, compromised cardiac function, or anaphylaxis, which requires immediate intervention.
D. While assessing peripheral sensation and movement is important for overall neurological function, it is not a priority in this context compared to assessing vital signs that can directly affect the client’s stability.
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Correct Answer is A
Explanation
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Correct Answer is D
Explanation
A. Calling a rapid response may be necessary if the client's condition deteriorates, but it is not the immediate priority in this scenario where the client is still able to be aroused.
B. Administering naloxone is appropriate if there is suspicion of opioid overdose; however, the priority is to address the low oxygen saturation first with non-invasive measures.
C. Checking the temperature and applying warmed blankets may be important, but the immediate concern is the low oxygen saturation.
D. Encouraging the client to take deep breaths is the most appropriate immediate action to improve oxygen saturation levels and enhance ventilation, as the client is in a post-anesthesia state where respiratory depression can occur.