NCLEX-RN Quiz
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PHYSIOLOGICAL INTEGRITY
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A 73-year-old with heart failure is admitted to a medical-surgical unit for pneumonia. The nurse finds the client sitting upright, confused, and cyanotic. Assessment: gurgling respirations with copious secretions; respiratory rate 10/min, oxygen saturation 82% on 4 L/min nasal cannula, heart rate 54/min, blood pressure 102/60 mm Hg. Which intervention should the nurse perform FIRST?
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