A nurse is caring for a client who was involved in a motor-vehicle crash. The client reports shortness of breath and chest pain and asks the nurse, "Am I dying?" Which of the following actions should the nurse take first?
Explanation & Rationale
Choice A reason: Informing the provider is necessary, but it is not the first action. Before contacting the provider, the nurse must gather immediate data to assess the severity of the client’s condition. Without objective information, communication with the provider may be incomplete or delayed in urgency. Choice B reason: Obtaining a pulse oximetry reading is the priority because the client is experiencing shortness of breath and chest pain, which may indicate impaired oxygenation. Pulse oximetry provides rapid, non-invasive data about oxygen saturation, guiding immediate interventions. This step ensures that the nurse can quickly determine if supplemental oxygen or emergency measures are required. Choice C reason: Administering pain medication is important for comfort, but pain management is not the priority when the client shows signs of possible respiratory compromise. Addressing oxygenation and circulation must come before pain relief in acute trauma situations. Choice D reason: Requesting a chest x-ray is appropriate for diagnostic purposes, but it is not the first action. Imaging takes time and requires physician orders. Immediate assessment of oxygenation is more urgent to stabilize the client before further diagnostics.