The practical nurse (PN) is caring for a client who is experiencing overwhelming anxiety and difficulty performing self care. Which question should the PN ask first?

A. Repeat the total bed bath and complete linen change: Repeating a full bed bath is not necessary unless the client is extensively soiled. It is more efficient and less disruptive to clean only the areas affected by incontinence while ensuring comfort and hygiene are maintained.
B. Place incontinent pads around the client's buttocks: While using incontinent pads helps manage future incontinence, it does not address the immediate need to clean the client and remove soiled linens, which is crucial to prevent skin breakdown and infection.
C. Cleanse any soiled skin and change the soiled linens: Cleaning the soiled skin and changing the linens is the best immediate response to maintain skin integrity, prevent infection, and promote client comfort. This targeted approach ensures the client remains clean without unnecessary interventions.
D. Spray a skin protectant around the perineal area: Applying a skin protectant is a helpful preventive measure after cleansing, but it should not be the first step. The priority is to remove feces and soiled linens before considering protective applications to the skin.

A. Notify the charge nurse: Although informing the charge nurse is important when a client’s status changes, it should be done after gathering objective data. Immediate assessment is critical to determine the extent of dyspnea and guide further interventions, rather than escalating prematurely without vital information.
B. Apply a pulse oximeter: Applying a pulse oximeter is the first action because it quickly assesses oxygen saturation and provides objective data regarding respiratory compromise. This measurement is essential to prioritize and tailor further interventions, ensuring timely management of potentially life-threatening hypoxia.
C. Observe pressure areas: Monitoring pressure areas is important for preventing pressure injuries in bedfast clients, but it is not the priority when a client is experiencing respiratory distress. Dyspnea requires immediate evaluation of oxygenation status rather than a skin integrity assessment.
D. Measure blood pressure: Blood pressure assessment provides information about cardiovascular status but does not immediately evaluate oxygenation. While important in overall evaluation, it is not the first step when addressing acute dyspnea, where oxygen saturation takes precedence to guide urgent care decisions.