Nursing Acceleration Challenge Exam (NACE) PN-RN Practice Test

In the event of a patient's respiratory distress, which action should a nurse take first?

1. Assess the patient's airway

2. Administer oxygen

3. Call for assistance

4. Position the patient to aid breathing

The correct answer is: Assess the patient's airway

In a situation where a patient is experiencing respiratory distress, the priority action for the nurse is to assess the patient's airway. This is crucial because the airway is foundational to adequate respiration and oxygenation. Without a clear airway, other interventions such as administering oxygen or positioning the patient may not be effective. By assessing the airway first, the nurse can determine if it is patent (open) or if there are obstructions that need to be addressed immediately. If the airway is compromised, the nurse can initiate necessary interventions such as suctioning or positioning the patient to ensure it remains open before considering other actions. This prioritization is in alignment with the ABCs of emergency care, where "A" for airway takes precedence over breathing and circulation. It is vital to ensure that breathing can occur effectively, which is why confirming the patency of the airway is the first step in managing respiratory distress. After ensuring the airway is secure, the nurse can then proceed with other interventions such as administering oxygen, calling for assistance, or positioning the patient appropriately to facilitate easier breathing.