While taking vital signs, the nurse notes a client leaning forward with arms on the bedside table, using accessory muscles, and flaring the nares. These signs are new. What should the nurse do?

1. 1Finish obtaining the remaining vital signs first, then report them
2. 2Reposition the client flat in bed and recheck the pulse oximeter
3. 3Reassess the client in one hour and report only if no improvement occurs
4. 4Immediately notify the health care provider or follow agency protocol

Source: Nursing Skills, 2nd edition (Open RN, Chippewa Valley Technical College, 2023), General Survey: Respiratory Rate. Licensed under CC BY 4.0.