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 A
Explanation
Choice A rationale
Sucking chest wounds impair oxygenation, posing a direct threat to life. Signs of shock (88/58 mm Hg, heart rate 115/min) demand immediate intervention. Red tag classification reflects life-threatening but treatable conditions needing priority care.
Choice B rationale
Significant penetrating head wounds with irregular breathing indicate brainstem damage, which usually leads to poor outcomes. Black tag assignment denotes expectant management due to un-survivable injuries.
Choice C rationale
Superficial lacerations with stable vitals (118/78 mm Hg) and occlusive dressing in place ensure no life-threatening issues. Green tag indicates minimal care urgency, requiring no immediate intervention.
Choice D rationale
Closed lower leg injuries causing severe pain do not compromise airway, breathing, or circulation. Yellow tag classification reflects delayed medical needs, prioritizing resources for more critical cases.
Correct Answer is D
Explanation
Choice A rationale
Numerical pain scales rely on the client’s ability to quantify pain verbally, which is often impractical or unreliable in dementia clients due to cognitive and communication impairments.
Choice B rationale
Verbal descriptions require clear articulation and comprehension, which can be challenging for clients with dementia; alternative non-verbal assessments are more effective in evaluating their pain levels.
Choice C rationale
The FACES scale is primarily used for children or cognitively intact clients who can associate facial expressions with pain intensity, making it less reliable for non-verbal dementia clients.
Choice D rationale
Behavioral indicators, such as grimacing or restlessness, provide observable, objective measures of pain in dementia clients who cannot communicate effectively, ensuring accurate pain assessment and appropriate management.
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