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 A
Explanation
Choice A rationale
Donning appropriate personal protective equipment (PPE), including an N95 respirator mask, face shield, gown, gloves, and shoe coverings, is crucial to protect the nurse from potential exposure to the virus during close contact with a symptomatic client.
Choice B rationale
Teaching the client to wear a mask, hand wash, and maintain social distance is essential for preventing virus spread but is secondary to protecting the healthcare provider while collecting a test sample from a symptomatic client.
Choice C rationale
Informing the client to notify others about potential exposure is an important step in contact tracing, but it does not directly protect the nurse during the specimen collection procedure.
Choice D rationale
Notifying the charge nurse about the client's need for assignment to a COVID-19 designated area is important for appropriate care and isolation but does not directly address immediate protection for the nurse during the testing procedure.
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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