Question

A client presents to the emergency room complaining of dyspnea, shortness of breath, and a productive cough. The vital signs are temperature \(101.4^{\circ} \mathrm{F}\), respiratory rate 30 , heart rate 108 , and \(\mathrm{BP} 124 / 80\). The client is receiving oxygen, with an oxygen saturation rate of \(86 \%\). Which of the following physician's orders should the nurse complete first? A. Obtain a chest \(x-r a y\) B. Administer acetaminophen (Tylenol) \(\mathrm{X}\) grain C. Obtain arterial blood gases D. Administer chlorpheniramine/hydrocodone (Tussionex)

Short answer

Answer: The nurse should first complete the order to obtain arterial blood gases.

Step-by-step solution

Review the information

Firstly, review the given information: the client's symptoms, vital signs, and oxygen saturation rate. Here are the main points: - Symptoms: dyspnea, shortness of breath, and a productive cough - Vital signs: temperature \(101.4^{\circ}\mathrm{F}\), respiratory rate \(30\), heart rate \(108\), and \(\mathrm{BP} 124/80\) - Oxygen saturation rate: \(86\%\)

Examine the physician's orders

Next, examine the four physician's orders to determine which should be completed first: A. Obtain a chest \(x-r a y\) B. Administer acetaminophen (Tylenol) \(\mathrm{X}\) grain C. Obtain arterial blood gases D. Administer chlorpheniramine/hydrocodone (Tussionex)

Determine the priority

Now we need to determine which order is the most critical for treating the patient: - A chest \(x - r a y\) will provide diagnostic information, but it won't provide immediate relief to the client. - Administering acetaminophen (Tylenol) would help reduce the client's fever, but it will not address their breathing issues. - Obtaining arterial blood gases is essential to assess the client's oxygenation status, which is a critical finding in this situation. - Administering chlorpheniramine/hydrocodone (Tussionex) may help suppress the cough, but it does not address the low oxygen saturation rate directly.

Choose the first order to complete

Since the client's low oxygen saturation rate is the most urgent issue to address, we can determine that the first order the nurse should complete is: C. Obtain arterial blood gases This will give a better understanding of the client's oxygenation status and is the most crucial step in treating the patient's condition at this stage.