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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Decreased calcium levels: Hypocalcemia may cause neuromuscular symptoms such as tetany or tingling but is not associated with exophthalmos (protruding eyes). Calcium imbalance does not typically cause changes in eye appearance.
B. Decreased somatotropin levels: Somatotropin (growth hormone) deficiency may lead to growth delay or reduced muscle mass, but it is not associated with changes in orbital appearance. Protruding eyes are unrelated to growth hormone levels.
C. Increased glucose levels: Elevated glucose is characteristic of diabetes mellitus and may lead to complications like neuropathy or retinopathy, but it does not cause eye protrusion.
D. Increased T4 levels: Elevated thyroxine (T4) is seen in hyperthyroidism, particularly in Graves' disease, which is strongly associated with exophthalmos. The protrusion results from inflammation and edema of orbital tissues, a hallmark of this thyroid disorder.
Correct Answer is D
Explanation
Rationale:
A. Verify the alarm settings on the ventilator: Ensuring alarms are properly set is a routine safety check but does not directly address the client's agitation or risk of self-extubation. It is important but not the priority action in this scenario.
B. Turn on the television: Providing distraction may help reduce mild anxiety but is insufficient for managing significant agitation in a mechanically ventilated client who may become dangerous to themselves if they pull out the endotracheal tube.
C. Obtain a prescription for a vest restraint: Physical restraints should be a last resort after attempting less restrictive methods. Using restraints without addressing the underlying cause of agitation (e.g., discomfort, anxiety, pain) can increase distress and injury risk.
D. Administer a sedative medication: Sedation is appropriate for a mechanically ventilated client who is agitated and at risk for self-extubation. Sedatives help ensure patient comfort, reduce anxiety, and promote ventilator synchrony while protecting the airway.
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