A hospitalized client with Hodgkin’s disease is at risk for ineffective airway clearance and impaired gas exchange related to compression of the trachea by enlarged lymph nodes. Which of the following measures would the nurse take first to help ensure that breathing and blood oxygen saturation are remaining adequate?
1. Administer oxygen per the physician’s orders.
2. Assess respiratory status during each shift.
3. Place the client in semi- to high-Fowler’s position.
4. Restrict visitors and unnecessary personnel.
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