A 45-year-old male presents with a blood pressure of 150/95 mm Hg, pulse 88/min, temperature 37.5°C, respirations 22/min, and SpO2 92%. Which intervention should the nurse prioritize?
Initiate oxygen therapy.
Monitor the patient for signs of infection.
Reassess the patient's temperature.
Administer antihypertensive medication.
The Correct Answer is A
A. Initiating oxygen therapy is the priority because the patient’s SpO₂ is 92%, which is below the normal range (95–100%) and indicates mild hypoxemia. Ensuring adequate oxygenation takes precedence over other interventions to prevent tissue hypoxia.
B. Monitoring for infection is not the immediate priority; the patient shows no overt signs of infection, and vital signs other than SpO₂ do not indicate an acute infectious process.
C. Reassessing the temperature is important for routine monitoring, but it does not address the immediate concern of low oxygen saturation.
D. Administering antihypertensive medication is necessary to manage elevated blood pressure, but it is secondary to correcting hypoxia, as oxygenation is essential for all organ function.
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Related Questions
Correct Answer is D
Explanation
A. Asking the patient to tolerate discomfort ignores their immediate needs and can cause pain, injury, or loss of trust.
B. Continuing quickly does not address the underlying cause of discomfort and may increase the risk of harm.
C. Applying more force is unsafe, can cause injury, and disregards the patient’s reported discomfort.
D. The most appropriate action is to stop the repositioning process and assess the cause of discomfort. This ensures patient safety, identifies potential issues such as pressure points, contractures, or pain from medical conditions, and allows the nurse to adjust the technique or provide pain management before continuing. Patient-centered care prioritizes comfort and safety.
Correct Answer is D
Explanation
A. Palliative care can be provided in a variety of settings, including the client’s home, outpatient clinics, hospitals, or hospice programs. It does not require admission to a skilled facility, so the client’s statement reflects a misunderstanding of service flexibility.
B. Providing relief for caregivers is the primary purpose of respite care, not palliative care. While palliative care may indirectly support caregivers by managing the client’s symptoms, its main focus is on the client’s comfort and quality of life.
C. Assistance with meals may be available through home health services or supportive care programs, but this is not a core component of palliative care. Palliative care prioritizes symptom management, emotional support, and comfort rather than daily living assistance.
D. Palliative care focuses on improving quality of life by managing pain and other distressing symptoms, addressing emotional and spiritual needs, and providing comfort for clients with serious or terminal illnesses. The client’s statement accurately reflects the primary purpose of palliative care.
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