A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?

A. Call emergency services for the client: While difficulty breathing is a concerning symptom, the immediate priority is to assess the client's respiratory status to determine the cause and appropriate interventions. Calling emergency services may be necessary based on the assessment findings, but assessment comes first.

B. Increase the oxygen flow to 3 L/min: Adjusting oxygen flow may be part of the intervention, but it should be based on a comprehensive assessment of the client's respiratory status. Simply increasing the oxygen flow without a thorough assessment may not address the underlying issue.

C. Have the client cough and expectorate secretions: This action may be appropriate if the client is experiencing difficulty breathing due to increased bronchial secretions. However, assessment is needed to determine the cause of the difficulty breathing before implementing interventions.

D. Assess the client's respiratory status: This is the correct answer. Assessment is the priority when a client with COPD on oxygen reports difficulty breathing. The nurse should gather information about the client's respiratory rate, effort, oxygen saturation, lung sounds, and overall respiratory distress to determine the appropriate course of action.

A. Impaired tissue perfusion: While impaired tissue perfusion is a concern in clients with varicose veins, the presence of ulcerations indicates that skin integrity is already compromised. Addressing impaired skin integrity is a more immediate concern.

B. Alteration in activity tolerance: Alteration in activity tolerance may be a consequence of impaired tissue perfusion and impaired skin integrity, but the priority is to address the current skin breakdown and prevent further complications.

C. Impaired skin integrity: This is the correct answer. The presence of varicose veins, ulcerations, and lower extremity edema indicates compromised skin integrity. The nurse should prioritize interventions to promote wound healing, prevent infection, and address the underlying causes contributing to impaired skin integrity.

D. Alteration in body image: While body image concerns may arise in clients with varicose veins, the immediate priority is addressing the physical complications such as impaired skin integrity to prevent further deterioration.