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 C
Explanation
Nausea and vomiting are common side effects of doxycycline, an antibiotic commonly used to treat chlamydial infections. Taking the medication with food or a snack can help alleviate these side effects. The recommendation to take the medication with crackers provides a light source of carbohydrates that can help settle the stomach and reduce nausea.
It is generally not recommended to take doxycycline with calcium-rich foods or beverages, as they can interfere with the absorption of the medication. Calcium can form complexes with doxycycline, reducing its effectiveness. Therefore, it is best to avoid calcium-rich foods and beverages, including calcium-fortified orange juice, when taking doxycycline.
Similar to calcium-rich foods, antacids can also interfere with the absorption of doxycycline. Antacids contain aluminum, magnesium, or calcium, which can bind to doxycycline and reduce its effectiveness. Therefore, it is generally recommended to avoid taking doxycycline with antacids.
While it is important to remain upright for a short period after taking some medications to prevent reflux or aspiration, this recommendation may not specifically address the client's nausea and vomiting. Taking the medication with food, such as crackers, may be more effective in alleviating the symptoms.
Correct Answer is A
Explanation
Placing soiled linens on the floor can lead to cross-contamination and the spread of infectious agents. This can pose a risk to the immunocompromised client, who may be more susceptible to infections.
Lining waste containers with single bags helps contain potentially infectious waste and facilitates proper disposal. This reduces the risk of contamination and exposure to infectious materials.
Using dampened cloths for dusting helps minimize the spread of dust and airborne particles. Dampening the cloth can help capture the dust and prevent it from becoming airborne, reducing the potential for respiratory exposure.
Placing uncapped sharps in a puncture-resistant container is an essential practice to prevent needlestick injuries and the transmission of bloodborne pathogens. This ensures safe disposal of sharps and reduces the risk of accidental needlestick injuries to healthcare workers and clients.
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