A client presents with a respiratory rate of 30min and oxygen saturation of 89%. What priority action should the nurse take?

A respiratory rate of 30 breaths per minute combined with an oxygen saturation of 89% indicates acute hypoxemia with increased work of breathing. This suggests impaired gas exchange, which may be caused by conditions such as pneumonia, airway obstruction, pulmonary edema, or respiratory distress. Immediate nursing priorities focus on restoring adequate oxygenation to prevent tissue hypoxia and organ dysfunction. Oxygen therapy is the first-line intervention to stabilize respiratory status. A. Calling for an ECG may be appropriate later if a cardiac cause such as dysrhythmia or myocardial ischemia is suspected, but it does not address the immediate problem of hypoxemia. The priority is to correct low oxygen saturation and respiratory distress first. Delaying oxygen administration could worsen cellular oxygen deprivation. B. Documenting the findings is an important nursing responsibility, but it is not the priority in an unstable patient. The combination of tachypnea and low oxygen saturation indicates an urgent respiratory compromise that requires immediate intervention. Documentation should follow stabilization of the patient’s airway and oxygenation. C. Administering supplemental oxygen is the priority action because it directly improves oxygen delivery to tissues. Oxygen therapy helps correct hypoxemia, reduce respiratory distress, and prevent progression to respiratory failure. This intervention supports adequate oxygen saturation while further assessment and treatment are initiated. D. Reassessing vital signs in 15 minutes delays necessary intervention in a patient showing signs of respiratory compromise. Waiting could allow worsening hypoxia and lead to organ dysfunction or cardiac arrest. Immediate action is required rather than delayed reassessment in this scenario.