A nurse is assessing an adult client and notes an increased respiratory rate of 28 breaths per minute and an oxygen saturation level of 89% on room air. Based on these findings, which of the following interventions should the nurse prioritize?

Administer oxygen therapy to improve the oxygen saturation level

Encourage the client to take deep breaths to improve lung expansion

Document the findings and monitor the client closely for changes

Position the client in a high-Fowler’s position

Answer and Explanation

The Correct Answer is D

Reasoning:

Respiratory insufficiency manifests as tachypnea and hypoxemia, indicating that the body’s metabolic demands are exceeding the current ventilatory and gas exchange capacity. Immediate nursing interventions must focus on optimizing lung volume and reducing the work of breathing to prevent further physiological exhaustion and potential respiratory collapse.

A. While administering oxygen therapy is a vital intervention for an oxygen saturation of 89%, it requires a provider's order or a standing protocol. The nurse should first implement independent nursing actions, such as positioning, while preparing to initiate oxygen to address the immediate clinical need for improved oxygenation.

B. Encouraging deep breaths may be helpful for someone with minor atelectasis, but a client with a respiratory rate of 28 and low saturation is in active distress. Deep breathing alone is unlikely to correct significant hypoxemia and does not address the mechanical disadvantage of the current body position.

C. Documenting and monitoring is a passive response that is inappropriate for an acute change in respiratory status. An oxygen saturation below 90% is a clinical red flag that requires active intervention to stabilize the client. Waiting to see if the condition changes could lead to avoidable complications.

D. Positioning the client in a high-Fowler’s position is the priority independent nursing action. This position allows for maximum diaphragmatic excursion and chest expansion by utilizing gravity to pull the abdominal contents downward. It reduces the work of breathing and is the fastest way to improve ventilation.

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Correct Answer is A

Explanation

Reasoning:

Flexion is a fundamental musculoskeletal movement occurring in the sagittal plane that involves the contraction of agonist muscles. This movement is essential for functional activities and is assessed during a physical exam to determine the joint's functional integrity and the presence of any mechanical obstructions or neuromuscular limitations.

A. Flexion is scientifically defined as a movement that decreases the angle between two body parts or bones at a joint. For example, bending the elbow or bringing the chin toward the chest are acts of flexion. This movement usually involves the shortening of the flexor muscle groups to approximate the bones.

B. Straightening a limb is defined as extension, which is the physiological opposite of flexion. Extension increases the angle between the bones at a joint, typically returning a body part to the anatomical position. If the movement exceeds the anatomical limit of 180 degrees, it is classified as hyperextension.

C. Moving a limb away from the midline of the body is known as abduction. This movement occurs in the frontal plane and is controlled by abductor muscle groups. An example is raising the arm laterally away from the torso. This is distinct from flexion, which focuses on the joint angle.

D. Rotating a limb toward the body's midline is referred to as internal or medial rotation. Rotation involves a bone turning around its longitudinal axis. While rotation is an important component of range of motion for ball-and-socket joints, it does not involve the angular reduction characteristic of flexion.

A. Bladder emptying without residual urine B. Bladder pain and discomfort C. Urinary frequency with small amounts D. Nocturia with frequent urination at night

Correct Answer is D

Explanation

Reasoning:

Benign prostatic hyperplasia involves the nonmalignant hypertrophy of the prostate gland, which leads to the mechanical compression of the prostatic urethra. This obstruction results in lower urinary tract symptoms (LUTS) as the bladder must work harder to overcome the resistance to urine outflow.

A. Complete bladder emptying is unlikely in a client symptomatic for BPH. The urethral obstruction typically leads to chronic urinary retention and significant post-void residual (PVR) urine. This residual volume contributes to the sensation of incomplete emptying and increases the risk of developing cystitis or bladder stones.

B. While BPH can cause a sensation of fullness or pressure, acute bladder pain is not a standard finding unless there is a secondary complication like a urinary tract infection or acute urinary retention. The progression of BPH symptoms is typically gradual and obstructive rather than acutely painful.

C. Although frequency occurs, the hallmark of the obstructive phase of BPH is the inability to initiate and maintain a strong stream. While "frequency with small amounts" describes the outcome, the most specific and universally reported nocturnal symptom that disrupts the quality of life in these patients is nocturia.

D. Nocturia is one of the most common and bothersome symptoms of BPH. As the bladder fails to empty fully during the day, residual volume builds up, and the bladder's functional capacity is reached more quickly at night. This necessitates multiple trips to the bathroom, significantly disrupting sleep patterns.

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A nurse is assessing an adult client and notes an increased respiratory rate of 28 breaths per minute and an oxygen saturation level of 89% on room air. Based on these findings, which of the following interventions should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client with range of motion exercises. Which of the following movements should the nurse perform to demonstrate flexion?

Correct Answer is A

Explanation

A client with a history of benign prostatic hyperplasia (BPH) presents with urinary hesitancy and weak stream. Which finding during assessment would be expected?

Correct Answer is D

Explanation

The nurse notes that a client's urinary frequency is paired with small voids. Which additional finding would most likely indicate urinary retention?

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A nurse is teaching a client about the epidermis. Which of the following information should the nurse include?

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