Identifying Respiratory Conditions - NCLEX-PN

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Question

A client had just undergone a total right knee replacement and has just returned from the operating room. Later that evening, the client suddenly begins to complain of shortness or breath and chest pain on inspiration. The nurse caring for this client further notes the coughing up of blood and that he is sweating profusely.

Which of the following nursing interventions should the nurse perform first?

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Answer

The priority for this client is to ensure a patent airway by placing him the Fowler's or semi upright seated position. Giving oxygen is warranted but will be given after the client is positioned correctly. ABG's would be helpful in this situation but it not the priority. Auscultation of breath sounds and assessment of mental status are not indicated.

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