A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations. Which of the following is the priority action by the nurse?
Establish a patent airway for the client
Administer oxygen to the client
Place a pulse oximeter on the client's finger
Check the client's pulse rate
The Correct Answer is A
A respiratory rate of 8 breaths per minute with shallow respirations and cyanosis indicates significant respiratory distress and inadequate oxygenation. The client's airway needs to be assessed and cleared to ensure a proper flow of air into the lungs. This can involve positioning the client appropriately, providing manual or mechanical assistance with ventilation, or using other airway management techniques as necessary.
While administering oxygen to the client and placing a pulse oximeter on the client's finger are important interventions to improve oxygenation and monitor oxygen saturation, they should not delay the immediate priority of establishing a patent airway.
Checking the client's pulse rate is also important and should be done in a timely manner, but it should not take precedence over ensuring a clear and open airway for the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Stopping dialysis is a significant decision made by the client, and it is important for the nurse to respect and support the client's autonomy and right to make decisions about their own healthcare. The nurse should provide emotional support, validate the client's feelings and concerns, and ensure that the client has access to appropriate resources and support systems. It is not the nurse's role to persuade or encourage the client to continue or reconsider the decision.
The other options are incorrect:
Tell the client she should discuss this decision with her family: While family involvement and support are important, the decision to stop dialysis ultimately rests with the client. It is the client's decision to make, and the nurse should respect the client's autonomy.
Discuss alternative treatment methods with the client: If the client has made an informed decision to stop dialysis, it is not appropriate for the nurse to discuss alternative treatment methods at this point. The focus should be on supporting the client in their decision and providing comfort and care.
Ask the facility chaplain to visit the client: Spiritual and emotional support can be valuable for clients facing end-of-life decisions, but it should be based on the client's preferences and requests. The nurse can offer spiritual support if desired but should not assume that it is necessary or appropriate in every case.
Correct Answer is ["C","D","E","F"]
Explanation
Case management can be beneficial in situations involving assault to help coordinate and provide ongoing support and resources for the client. This intervention is appropriate in this scenario.
Ensuring a safe and private environment is crucial to protect the client's confidentiality and provide a supportive atmosphere during this difficult time. This intervention is necessary. Since the client reports being assaulted and has sore genitals, it is important to consider the risk of sexually transmitted infections (STIs). Administering STI prophylaxis can help prevent potential infections.
The client may benefit from additional support services such as counseling or support groups. Providing resources for local support services can help the client access the necessary help and support they need.
Contacting children and youth services is not applicable in this scenario as the client is a full-time college student and not a child or youth.
While the client mentioned drinking, it is not explicitly stated that they have an alcohol addiction or problem. Therefore, providing resources for Alcoholics Anonymous may not be the most appropriate intervention at this time.
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