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
Exercising close to bedtime increases adrenaline and body temperature, which interfere with sleep initiation. Studies recommend ceasing vigorous activity at least 3-4 hours before bedtime to optimize sleep quality.
Choice B rationale
Reducing fluid intake before bed minimizes nocturia, a common sleep disturbance. This aligns with promoting uninterrupted sleep and improving overall sleep hygiene and quality for individuals with insomnia.
Choice C rationale
Taking daytime naps, especially longer than 30 minutes, disrupts circadian rhythms and sleep drive, contributing to difficulty initiating and maintaining sleep during regular hours.
Choice D rationale
Eating a large meal before bedtime delays gastric emptying and may cause discomfort or reflux, both of which interfere with falling asleep. Light snacks are recommended if needed, but not heavy meals.
Correct Answer is A
Explanation
Choice A rationale
Visualizing a favorite place promotes relaxation by stimulating the parasympathetic nervous system, reducing sympathetic overactivity linked to anxiety, and aiding focus by engaging the brain's positive imagery pathways.
Choice B rationale
Choosing a word to help focus attention is a mindfulness technique, but it is associated with mantra meditation rather than general relaxation approaches to alleviate anxiety.
Choice C rationale
Holding the breath for 90 seconds can exacerbate anxiety, potentially leading to hyperventilation or hypoxia, which contradicts the therapeutic goals of meditation practices.
Choice D rationale
Meditating for 1 hour daily is impractical for most beginners, and starting with shorter sessions is more effective in fostering adherence and reducing anxiety.
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