A 28 year old patients presents with lower abdominal pain pelvic pain and chills, nausea, and vomiting. She is sexually active with many partners and reports she taking oral contraceptive .She’s having increased shortness of breath .Vital signs T-99 HR 145 BPM BP 100/48 RR22 SPO2 94% room air pain 10/10.she is viably diaphoretic with cap refill >3 seconds.The nurse auscultates fait crackles in the bilateral lung bases . the patient reports “i feel like i cant breathe , my chest is really tight.

Identify three nursing interventions for the patient and provide rationale for the assessment criteria identified .