A nurse is caring for a client who is receiving oxygen at 5 L/min via nasal cannula and is hypoxic. Which of the following actions is the nurse's priority?

Prepare to intubate the client with an endotracheal tube.

Place a nonrebreather face mask.

Obtain a prescription for arterial blood gases.

Apply noninvasive positive-pressure ventilation.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Prepare to intubate the client with an endotracheal tube: Intubation is an invasive intervention typically reserved for clients with severe or rapidly deteriorating respiratory failure. It is not the first step in managing hypoxia when simpler oxygen delivery methods may be effective.

B. Place a nonrebreather face mask: This is the priority action because a nonrebreather mask delivers high-concentration oxygen (up to 95–100%) and can rapidly correct hypoxia. It is the most appropriate next step when a nasal cannula at 5 L/min is insufficient.

C. Obtain a prescription for arterial blood gases: While important for assessing the severity of hypoxia and guiding further treatment, this diagnostic action does not immediately address the client’s oxygenation needs.

D. Apply noninvasive positive-pressure ventilation: This intervention is beneficial for clients with certain conditions like COPD or heart failure but may not be the first-line response for general hypoxia. A nonrebreather mask is simpler and faster to apply in an acute setting.

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Correct Answer is C

Explanation

Rationale:
A. The client's bed has a three-prong plug attached to the electrical cord: A three-prong plug provides grounding and is a standard safety feature. It helps prevent electric shock and is not considered a hazard.

B. A protective cover is inserted into an unused outlet: Outlet covers are recommended, especially in homes with children, to prevent accidental electrical shock. This is a safety measure, not a hazard.

C. An IV pump is plugged into an outlet near a sink: This is a safety hazard because electrical devices should not be used near water sources. The proximity to the sink increases the risk of electrical shock or short-circuiting if moisture contacts the outlet or device.

D. An electrical cord is coiled and secured to the floor: Coiling and securing cords can prevent tripping hazards and is generally acceptable as long as the cord is not damaged or covered in a way that could lead to overheating.

A. "I will take my temperature daily." B. "I will wash my toothbrush weekly." C. "I will eat plenty of fresh fruits and vegetables." D. "I will change my cat's litter box twice weekly." E. "I will avoid crowds."

Correct Answer is ["A","E"]

Explanation

Rationale:

A. "I will take my temperature daily.": Daily temperature monitoring is essential for clients with neutropenia, as even a low-grade fever may be the only early sign of infection due to suppressed immune response. Prompt detection allows for early intervention and treatment.

B. "I will wash my toothbrush weekly.": A neutropenic client should wash or replace their toothbrush more frequently—ideally daily or after each use—to reduce the risk of bacterial growth and oral infections, which they are more vulnerable to.

C. "I will eat plenty of fresh fruits and vegetables.": Fresh, uncooked fruits and vegetables may carry harmful bacteria or fungi and should be avoided unless thoroughly washed or cooked. A neutropenic diet typically excludes raw produce to minimize infection risk.

D. "I will change my cat's litter box twice weekly.": Clients with neutropenia should avoid handling cat litter altogether, as it can harbor Toxoplasma gondii and other pathogens that pose a serious infection risk due to their weakened immune system.

E. "I will avoid crowds.": Avoiding crowds is critical for clients with neutropenia to reduce exposure to airborne and contact-transmissible pathogens, as even minor infections can become life-threatening in immunocompromised individuals.

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