A client with laboured, dyspneic breathing, wheezes, and anxiety requires initial intervention. Which action should the practical nurse take first?

A client with laboured, dyspneic breathing, wheezes, and anxiety requires initial intervention. Which action should the practical nurse take first?

• A. Chart her findings and report to the nurse team leader.
• B. Encourage the client to deep breathe and cough.
• C. Elevate the head of the bed and administer oxygen.
• D. Go to the nurses' station and call the physician.

Answer: (C)

When a client is experiencing labored, dyspneic breathing with wheezes and anxiety, the first priority is to support breathing and ensure adequate oxygenation. Elevating the head of the bed helps expand the chest and reduces the work of breathing, making it easier to ventilate. Administering supplemental oxygen addresses potential hypoxemia and is a primary immediate intervention in respiratory distress. These steps align with the ABCs of basic rescue care: airway and then breathing come before other actions like documentation or consulting the physician. Documentation and reporting are important, but they follow once the client is stabilized. Encouraging deep breathing and coughing may be useful later, but during acute distress it isn’t the immediate priority. If the provider’s orders are in place, start oxygen promptly and monitor the client’s response, including oxygen saturation and vital signs, then reassess and proceed with further assessment or escalation as needed.

When a client is experiencing labored, dyspneic breathing with wheezes and anxiety, the first priority is to support breathing and ensure adequate oxygenation. Elevating the head of the bed helps expand the chest and reduces the work of breathing, making it easier to ventilate. Administering supplemental oxygen addresses potential hypoxemia and is a primary immediate intervention in respiratory distress. These steps align with the ABCs of basic rescue care: airway and then breathing come before other actions like documentation or consulting the physician.

Documentation and reporting are important, but they follow once the client is stabilized. Encouraging deep breathing and coughing may be useful later, but during acute distress it isn’t the immediate priority. If the provider’s orders are in place, start oxygen promptly and monitor the client’s response, including oxygen saturation and vital signs, then reassess and proceed with further assessment or escalation as needed.