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A nurse is caring for a client with the following vitals: T-99.1, P-110, R-30, 130/76, O2-91% on room air. Which of the following prescribed interventions is the nurse's priority action? a) Administering pain medication b) Administering oxygen therapy c) Monitoring blood pressure d) Assessing respiratory rate

Answer :

Final answer:

Based on the patient's vitals, the nurse's priority action should be administering oxygen therapy since the patient's above-normal respiratory rate and low oxygen saturation indicate potential respiratory distress.

Explanation:

In the scenario presented, a nurse is caring for a client who has the following vitals: T-99.1, P-110, R-30, 130/76, O2-91% on room air. The prioritized interventions for this case are: a) administering pain medication, b) administering oxygen therapy, c) monitoring blood pressure, and d) assessing respiratory rate. Based on the vital signs given, the patient's heart rate (P-110) and respiratory rate (R-30) are higher than normal, indicating potential respiratory distress. The oxygen saturation (O2) of 91% on room air is also lower than the typical range of 95%-100%, suggesting hypoxemia, or low blood oxygen content. Therefore, the nurse's priority action from the given options should be b) administering oxygen therapy to alleviate the patient's respiratory distress and increase the oxygen saturation level, which could directly improve the heart rate and respiratory rate.


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