A nurse in the emergency department is caring for a female client who reports shortness of breath and pain in the chest. The client states she began taking oral contraceptives 3 weeks ago and that she smokes. Her vital signs are: heart rate 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Arterial blood gas results are: pH 7.50, PaCO₂ 29 mm Hg, PaO₂ 60 mm Hg, HCO₃⁻ 20 mEq/L, and SaO₂ 86%. Which of the following is the priority nursing intervention?
Administer oxygen via face mask
Prepare for mechanical ventilation
Prepare to administer a sedative
Assess for indications of pulmonary embolism
The Correct Answer is A
Rationale:
A. The ABGs show respiratory alkalosis (pH 7.50, PaCO₂ 29) with hypoxemia (PaO₂ 60, SaO₂ 86%). The priority is to administer oxygen via face mask to correct hypoxemia.
B. Mechanical ventilation may be needed if oxygen therapy is ineffective, but it is not the first action.
C. A sedative is not appropriate because the hyperventilation is compensatory for impaired oxygenation.
D. Assessing for pulmonary embolism is important (risk factors: oral contraceptives, smoking, sudden dyspnea), but ensuring oxygenation takes priority in the immediate situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Encouraging the client to drink 2 to 3 L of water daily helps thin tenacious secretions, making them easier to expectorate and improving airway clearance.
B. Maintaining a semi-Fowler's position promotes lung expansion and ease of breathing but does not directly thin secretions.
C. A low-salt diet may help manage fluid retention in some conditions but does not affect mucus viscosity in COPD.
D. Administering oxygen improves oxygenation but does not address the issue of thick bronchial secretions.
Correct Answer is ["A","D","E"]
Explanation
Rationale:
A. Relying on public transit can limit the client’s ability to obtain groceries and attend medical or nutrition appointments, creating a barrier to adequate nutrition.
B. Having an adult child visit is a source of support and does not represent a barrier; it may help the client meet nutritional goals.
C. Receiving supplemental nutrition assistance increases access to food resources and is not a barrier.
D. Dietary restrictions for chronic conditions are part of the treatment plan and guide appropriate intake; they do not inherently prevent the client from meeting nutritional goals.
E. Mobility impairment from arthritis can make cooking, shopping, and feeding difficult, creating a significant barrier to proper nutrition.
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