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 B

Explanation

A. Asthma: Asthma affects the respiratory system and does not have a direct link to urinary tract infections. It does not alter urinary tract anatomy or immune defenses specific to the urinary system.

B. Diabetes mellitus: Clients with diabetes are at increased risk for UTIs due to immune suppression, glucosuria that promotes bacterial growth, and possible bladder dysfunction (e.g., urinary retention) from diabetic neuropathy. Poor glycemic control further raises infection susceptibility.

C. Pernicious anemia: This condition is related to vitamin B12 deficiency and affects red blood cell production and neurological function, but it does not specifically predispose clients to UTIs.

D. Osteoporosis: Osteoporosis involves reduced bone density and is not associated with urinary tract infections. It does not impact the urinary or immune systems directly.

A. Continuous passive motion device B. Elevated toilet seat C. Trapeze bar D. Compression garment

Correct Answer is B

Explanation

Rationale:
A. Continuous passive motion device: This device is typically used following total knee arthroplasty to maintain joint mobility and prevent stiffness. It is not commonly indicated after total hip arthroplasty, where excessive hip movement is discouraged during early recovery.

B. Elevated toilet seat: An elevated toilet seat helps prevent excessive hip flexion, which reduces the risk of hip dislocation after surgery. It allows the client to sit and stand more safely without bending the hip beyond 90 degrees, which is a critical precaution following hip arthroplasty.

C. Trapeze bar: A trapeze bar may assist some clients in repositioning while in bed, but it is not a standard discharge requirement for hip arthroplasty. Its use is more common in inpatient rehabilitation or in clients with prolonged immobility.

D. Compression garment: While compression stockings may be used to reduce the risk of deep vein thrombosis (DVT), a compression garment is not a standard or essential piece of home equipment following hip replacement surgery unless specifically indicated by the healthcare provider.

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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?

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