A nurse is caring for a 70-year-old male client on a medical-surgical unit.
Which action should the nurse take next?
Administer a blood transfusion.
Monitor the client for signs of infection.
Reassess the insertion site for bleeding.
Notify the provider of the client's vital signs.
The Correct Answer is A
Choice A rationale: An oxygen saturation of 84% indicates severe hypoxemia. Normal oxygen saturation levels are between 95% and 100%. A level this low can impair tissue oxygenation and lead to life-threatening complications like respiratory failure or cardiac arrest.
Choice B rationale: An elevated blood pressure of 168/90 mm Hg, while concerning, does not immediately signify a life-threatening condition. It can be a result of distress or pain and needs management but is not as critical as severe hypoxemia.
Choice C rationale: A respiratory rate of 27/min is elevated but not immediately life-threatening. It indicates the body's effort to compensate for hypoxemia, but the underlying issue of low oxygen saturation is more critical to address.
Choice D rationale: A heart rate of 98/min, although increased, does not indicate a life-threatening condition. The elevation may be due to distress or medication side effects. Managing hypoxemia is more urgent to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Monitoring blood pressure trends ensures early detection of medication effectiveness, yet is secondary to addressing critical hypokalemia. Normal blood pressure is 120/80 mmHg; deviations warrant monitoring, but this is not the priority intervention.
Choice B rationale
Administering potassium chloride STAT addresses potential hypokalemia, which risks arrhythmias and muscle weakness. Normal potassium levels range between 3.5-5.0 mEq/L, highlighting urgency when potassium is below normal.
Choice C rationale
Reassessing additional medication needs at a set time ensures comprehensive care but does not address immediate life-threatening conditions like hypokalemia, which requires urgent correction to prevent cardiac dysfunction.
Choice D rationale
Educating about blood pressure maintenance is crucial for long-term management but does not address the immediate physiological imbalance or risk of arrhythmias due to electrolyte disturbance, making it a lower priority.
Correct Answer is C
Explanation
Choice A rationale
Administering antibiotics is crucial for meningitis management but should follow infection control protocols to prevent transmission, aligning with the prioritization of safety in Maslow's hierarchy of needs.
Choice B rationale
Providing analgesics manages symptoms but does not prevent disease spread. Initiating precautions addresses the immediate risk of contagion, which takes precedence in infection control.
Choice C rationale
Initiating droplet precautions minimizes the risk of disease transmission to healthcare providers and others, adhering to infection control standards and being the primary action in meningococcal meningitis.
Choice D rationale
Educating the client is important for understanding the illness, but immediate containment of the infectious agent through precautions is the priority in preventing disease spread.
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