Which action by the nurse takes the highest priority?
A client with suspected inhalation anthrax is admitted to the emergency department.
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A. Monitor vital signs and oxygen saturation every 15 to 30 minutes.
B. Suction the client as needed to obtain a sputum specimen for culture and sensitivity.
C. Assess intake and output and maintain adequate hydration.
D. Reassure the client that intubation and mechanical ventilation will be temporary.
The answer to this is A. The nurse should make the effort to check the patient’s vital signs every half hour. The patient’s oxygen saturation should also be monitored properly. These are the main things that should be done first. The others, like checking the sputum may also be needed but it can be done once and wait for the results to take place. After that, the patient’s intake and output should also be considered just to see if there are some secretions.
If there is none, then there is no need to check this anymore. D is not needed at all because there is no way of knowing at the present time if it is going to be temporary. There are also some patients who may not even realize what is happening. It may only confuse them more.
1. monitor vital signs and oxygen saturation every 15 to 30 minutes.
-rationale: monitoring vital signs and oxygen saturation every 15 to 30 minutes takes priority. suctioning the client as needed to obtain a sputum specimen may be necessary, but assessing the client for changes in his respiratory status takes priority. assessing intake and output and providing adequate hydration are important steps for liquefying secretions; however, they dont take priority. reassuring the client that intubation and mechanical ventilation is temporary is inappropriate. the client may not require intubation and mechanical ventilation; however, if he does, the nurse cant predict the length of time it may be necessary.
client needs category: safe, effective care environment
client needs subcategory: safety and infection control
cognitive level: analysis
reference: smeltzer, s.c., et al. brunner & suddarths textbook of medical-surgical nursing,11th ed. philadelphia: lippincott williams & wilkins, 2008, p. 2566.