A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority?
Answer: Monitor vital signs and oxygen saturation every 15 to 30 minutes.
Explanation:
Monitoring vital signs and oxygen saturation every 15 to 30 minutes takes priority. Suctioning the client as needed to obtain a sputum specimen may be necessary, but assessing the client for changes in his respiratory status takes priority. Assessing intake and output and providing adequate hydration are important steps for liquefying secretions; however, they don't take priority. Reassuring the client that intubation and mechanical ventilation is temporary is inappropriate. The client may not require intubation and mechanical ventilation; however, if he does, the nurse can't predict the length of time it may be necessary.
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