Mr. Tim is a 75-year-old presents to

Mr. Tim is a 75-year-old presents to the Emergency Department with his daughter whom he lives with. The daughter states Mr. Tim has had increased difficulty breathing over the past 2 weeks and has needed to sleep in the recliner with several pillows the last few nights. The daughter states, “The last couple days he has needed to stop and rest several times when getting ready for the day. He has not been able to get dressed without stopping several times due to being out of breath.” Mr. Tim has been a smoker for the past 62 years. The initial nursing assessment reveals the following: VS: BP 112/72, HR 106, RR 25, SpO2 88% on room air, Temp 100.3 °F Client is alert, and oriented x3, HR regular rhythm, diminished lung sounds with expiratory wheezes, use of accessory muscles, delayed capillary refill of nails, and cyanotic fingernail beds. 1. Prioritize the following nursing interventions and rationals ? ï‚· Complete a more comprehensive assessment ï‚· Raise the head of the bed ï‚· Apply oxygen at 2 L/nasal cannula ï‚· Encourage pursed-lip breathing SCIENCE HEALTH SCIENCE NURSING NU 424

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