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 125/88 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 20/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 75/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
While legal advice might assist, attorneys are not required to sign advance directives. Requirements vary by jurisdiction but typically involve witnesses or a notary for validity.
Choice B rationale
Living wills document clients’ preferences for medical care when decision-making is impaired. It is a central component of advance directives and demonstrates the client’s understanding.
Choice C rationale
Though appointing a health care proxy is an option, it is not mandatory for advance directives. Living wills alone can suffice to outline preferences without assigning a proxy.
Choice D rationale
Advance directives generally address situations where resuscitation is undesired, such as DNR orders, rather than requiring explicit documentation for resuscitation preferences, making this statement inaccurate.
NGN QUESTIONS
Correct Answer is D
Explanation
Choice A rationale
Suggesting that the situation will improve over time lacks therapeutic value and may dismiss the client’s current emotions, failing to provide active emotional support or promote coping mechanisms.
Choice B rationale
Acknowledging the difficulty of the situation validates the client’s feelings but does not encourage engagement in active coping strategies or provide constructive emotional assistance.
Choice C rationale
Recommending talking to a chaplain assumes the client’s preference for spiritual support without addressing their immediate concerns or fostering problem-solving and emotional expression.
Choice D rationale
Encouraging the client to reflect on past coping mechanisms promotes problem-solving, emotional expression, and the utilization of effective strategies previously used, fostering therapeutic engagement and resilience.
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