Patient Data Exhibits The rapid response team (RRT) is on its way to the bedside. Which 4 actions should the nurse perform immediately?

Rationale: A. Call for a stat chest x-ray: Although confirming the suspected pneumothorax with imaging is necessary, this action should follow immediate life-saving interventions. The client is already cyanotic and unstable, requiring oxygenation and airway support before diagnostic imaging. B. Collect supplies for a chest tube: The absence of breath sounds and chest rise on one side after thoracentesis strongly suggests a pneumothorax. Preparing chest tube supplies ensures that the healthcare provider can promptly insert the tube to re-expand the lung and restore ventilation. C. Suction the client: Since the client has a tracheostomy and thick secretions, airway obstruction may worsen hypoxia. Suctioning helps clear mucus, improve airflow, and facilitate oxygen delivery while awaiting further intervention. D. Replace the tracheostomy tube: Replacing the tracheostomy tube is not indicated unless it is dislodged or blocked, which is not stated in the scenario. Unnecessary manipulation could cause further airway compromise or trauma. E. Increase the client’s oxygen: Cyanosis indicates severe hypoxia, requiring immediate oxygen escalation to the highest safe concentration. Increasing FiO₂ helps stabilize oxygen saturation while the underlying cause is corrected. F. Place the client on a continuous pulse oximeter: Continuous pulse oximetry provides real-time monitoring of oxygenation status and helps evaluate the effectiveness of interventions. This allows for early detection of worsening hypoxia and guides rapid response efforts.