A licensed practical nurse (LPN) is making a home health visit to a 52-year-old woman with chronic obstructive pulmonary disease (COPD) who was discharged 3 days ago after an exacerbation treated with antibiotics and oral corticosteroids. The client is on contact precautions for a history of MRSA colonization. Baseline vital signs from yesterday's visit were BP 128/78, HR 88, RR 20, SpO2 94% on 2 L/min oxygen, with a follow-up recheck ordered for today. Today the client reports increased shortness of breath and thick yellow sputum. Vital signs are BP 132/80, HR 108, RR 26, temp 37.8°C, SpO2 88% on 2 L/min, and she is using accessory muscles to breathe, seated slightly slumped in a recliner. Which action should the nurse take first?
- Document the vital sign changes in the chart and continue with the rest of the scheduled visit, without notifying the RN or health care provider.
- Increase the oxygen flow rate independently to correct the low SpO2 reading.
- Assist the client into a high Fowler's position and reassess SpO2 and work of breathing, then notify the RN.
- Suction the client's oropharynx for 30 seconds to remove secretions before reassessing.