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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Explanation

A. Turn cellular phones to silent mode

Staff members should be advised to silence their cellular phones during an active shooter situation. This helps maintain silence and prevents the ringing or vibrating of phones from potentially revealing the location of individuals hiding or seeking shelter.

Move wounded clients to a safe area before finding shelter in (option B) is not correct. In the event of an active shooter situation. The safety of both staff members and clients is paramount. If it can be done quickly and without putting oneself or others at significant risk, moving wounded clients to a safe area before finding shelter may be advisable. However, the primary focus should be on finding shelter and protecting oneself from harm.

Attempt to bargain with the shooter in (option C) is not correct. Engaging in negotiations or attempting to reason with an active shooter can be extremely dangerous and may escalate the situation. Staff members should be instructed to prioritize their own safety and follow established active shooter protocols, which often involve evacuating, hiding, or acting to incapacitate or disable the shooter as a last resort.

Wave hands to attract the attention of law enforcement in (option D) is not correct. Waving hands or making sudden movements that may be misconstrued as threatening can potentially result in harm or confusion when law enforcement or security personnel are responding to an active shooter situation. It is important to follow their instructions calmly and clearly, keeping hands visible and following their guidance to ensure everyone's safety.

In summary, the nurse should recommend turning cellular phones to silent mode, moving wounded clients to a safe area if possible, not attempting to bargain with the shooter, and avoiding actions that may be misinterpreted by law enforcement. These recommendations are aimed at prioritizing personal safety and following established protocols to minimize risks during an active shooter situation.

A. Older adults are at risk for developing type 1 diabetes mellitus. B. Prednisone can cause blood glucose levels to increase. C. Albuterol treatments can cause blood glucose levels to decrease. D. Having COPD causes blood glucose levels to fluctuate.

Correct Answer is B

Explanation

Prednisone can cause blood glucose levels to increase.

The nurse should explain to the client that the reason for checking his blood glucose level is because prednisone, a medication he is receiving, can cause an increase in blood glucose levels. Prednisone is a corticosteroid medication that is commonly used in the treatment of various conditions, including COPD. It has the potential to raise blood glucose levels by promoting gluconeogenesis (the production of glucose from non-carbohydrate sources) and decreasing insulin sensitivity. Monitoring blood glucose levels is important to assess and manage any potential hyperglycaemia or changes in the client's blood sugar levels while on prednisone.

Older adults are not at increased risk for developing type 1 diabetes mellitus in (option A) is incorrect. Type 1 diabetes is an autoimmune condition that typically occurs in childhood or adolescence, and it is characterized by the destruction of insulin-producing cells in the pancreas.

Albuterol treatments, which are used to relieve bronchospasms in clients with COPD, are not known to cause blood glucose levels to decrease in (option C) is incorrect. Albuterol is a beta-2 adrenergic agonist that primarily acts on the respiratory system and does not have a direct effect on blood glucose levels.

Having COPD does not directly cause blood glucose levels to fluctuate in (option D) is incorrect. While there can be various factors that may indirectly affect blood glucose levels in individuals with COPD (e.g., medications, stress, comorbidities), the primary reason for monitoring blood glucose in this case is the use of prednisone.

In summary, the nurse should explain to the client that the blood glucose levels are being checked because prednisone, a medication he is taking for his COPD, can cause an increase in blood glucose levels. This allows for appropriate monitoring and management of any potential hyperglycemia associated with the use of prednisone.

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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?

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A nurse is assisting with planning an in-service for staff members about active shooter protocols. Which of the following information should the nurse recommend?

Correct Answer is A

Explanation

A nurse is assisting in the care of an older adult client who has COPD and is receiving albuterol treatments and 20 mg of prednisone twice daily. The client asks why the nurse is checking his blood glucose level. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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