HESI Registered Nurse EXIT Practice Exam

What should the nurse assess first in a client admitted with a chronic cough and wheezing?

1. Oxygen saturation

2. Alertness and orientation

3. Pulse rate

4. Blood pressure

The correct answer is: Oxygen saturation

In a client presenting with a chronic cough and wheezing, assessing oxygen saturation is critical because it provides immediate insight into the patient’s respiratory function and overall oxygenation status. Wheezing can indicate narrowed airways and potential bronchospasm, which can compromise the client’s ability to breathe effectively. Monitoring oxygen saturation helps determine if the patient is receiving adequate oxygen and identifies hypoxia, which requires urgent intervention. If the oxygen saturation is low, it can guide the nurse to take prompt actions, such as positioning the patient appropriately, administering supplemental oxygen, or preparing for other interventions. While alertness and orientation, pulse rate, and blood pressure are also important assessments, they do not directly address the immediate concerns surrounding respiratory distress. A thorough evaluation of the respiratory system should always take priority in this scenario to ensure the client's airway is safe and their oxygen needs are met.