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    Ati nurs 113 med surg sensory neuro proctored exam

    The nurse is performing morning care for a patient who sustained a fractured pelvis and bilateral femur fractures yesterday in a motorcycle collision. The patient complains of shortness of breath. Assessment reveals audible wheezes and oxygen saturation of 76%. What action should the nurse take first?

    Explanation & Rationale

    A. Explaining the situation to the family is important, but it is not a priority when the patient is in respiratory distress. B. Establishing an IV line may be necessary later for treatment, but it does not immediately address the low oxygen saturation or respiratory compromise. C. Raising the patient to a High Fowler’s position helps to maximize lung expansion and improve oxygenation, making it the first and most immediate action. D. Notifying the charge nurse is appropriate after the nurse takes action to stabilize the patient’s airway and breathing.

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