A 52-year-old patient on the surgical floor has a blood pressure of 128/72, a heart rate of 125 bpm, a respiratory rate of 32 breaths/min, and a temperature of 99.1 degrees Fahrenheit. The patient complains of severe shortness of breath. Which of the following should the nurse assess first?

Breath sounds

Explanation

•The clinical findings suggest a pulmonary embolism or other acute pulmonary problems. Therefore, lung sounds should be assessed first.

•A change in breath sounds will give the nurse more information regarding the patient's situation. Noting wheezing, stridor, or crackles will help in the clinical evaluation. A pulse oximetry reading should also be obtained.

•Heart sounds, peripheral circulation, and pupil reactivity are not first priority for assessment in this situation.

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