A nurse is caring for a 59-year-old male client in the intermediate care unit.
Oxygen saturation of 56%
Crackles heard in the right lung
pH of 7.21
Tracheal deviation to the right
Correct Answer : A,D
Choice A rationale: Oxygen saturation of 56% is critically low and indicates severe hypoxemia, which requires immediate intervention to improve oxygenation and prevent life-threatening complications.
Choice D rationale: Tracheal deviation to the right suggests a possible tension pneumothorax, which is a medical emergency. It requires immediate attention to relieve the pressure on the affected lung and restore normal breathing.
Choice B rationale: Crackles heard in the right lung indicate fluid or atelectasis but are not immediately life-threatening compared to the other findings.
Choice C rationale: A pH of 7.21 indicates acidemia and respiratory acidosis but is a secondary concern compared to the immediate need to address the client's hypoxemia and potential tension pneumothorax.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While asking the client's family to return may provide additional support, it is not a viable long-term solution as family members may have other responsibilities and commitments. It also places undue pressure on the family.
Choice B rationale
Hiring a private nurse could be a solution, but it may not be financially feasible for all clients. It also does not address the need for a comprehensive plan for both the client and her husband.
Choice C rationale
Social services can assist in arranging respite care for the client's husband, ensuring he receives the necessary care while the client recovers. Respite care is a practical solution for temporary relief for caregivers.
Choice D rationale
A case management evaluation can help assess the client's home environment and identify any potential needs or risks. However, it does not directly address the immediate concern of providing care for the husband.
Correct Answer is ["A","D"]
Explanation
Choice A rationale: Oxygen saturation of 56% is critically low and indicates severe hypoxemia, which requires immediate intervention to improve oxygenation and prevent life-threatening complications.
Choice D rationale: Tracheal deviation to the right suggests a possible tension pneumothorax, which is a medical emergency. It requires immediate attention to relieve the pressure on the affected lung and restore normal breathing.
Choice B rationale: Crackles heard in the right lung indicate fluid or atelectasis but are not immediately life-threatening compared to the other findings.
Choice C rationale: A pH of 7.21 indicates acidemia and respiratory acidosis but is a secondary concern compared to the immediate need to address the client's hypoxemia and potential tension pneumothorax.
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