You are assigned to care for Ms. C., an 81-year-old patient who was admitted today with symptoms of increasing shortness of breath over the last week. She is currently receiving oxygen through a nasal...

You are assigned to care for Ms. C., an 81-year-old patient who was admitted today with symptoms of increasing shortness of breath over the last week. She is currently receiving oxygen through a nasal cannula at 3 L/min. You go into the room to assess her. You find that she is sitting up in bed at a 60-degree angle. She is restless and her respirations appear labored and rapid. Her skin is pale with circumoral cyanosis. You ask if she feels more short of breath. Because she is unable to catch her breath enough to speak, she nods her head yes. Which action should you take first?

 Listen to her breath sounds.

  Ask when the shortness of breath started.

 Increase her oxygen flow rate to 6 L/min.

 Raise the head of the bed from 75 to 85 degrees

 Based on knowledge you have learned, you realize the patient’s symptoms indicate acute hypoxemia, so improving oxygen delivery is the priority. The other actions also are appropriate, but they are not as critical as the initial action.