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 ["A","C","E","F"]

Explanation

Rationale:

A. Upper arm and lower leg findings: The presence of ecchymoses indicates impaired coagulation, which is common in chronic liver disease due to decreased clotting factor production. In the context of active bleeding (hematemesis), this is significant and needs immediate evaluation.

B. Skin temperature: Cool and dry skin, while concerning, is a nonspecific symptom. It may support a diagnosis of hypovolemia or shock, but on its own, it does not require the same urgent intervention as abnormal vital signs or lab results.

C. Blood pressure: A BP of 92/56 mm Hg indicates hypotension and suggests the client may be experiencing hypovolemic shock from gastrointestinal bleeding. This finding requires immediate intervention to prevent end-organ damage.

D. Bowel sounds: Bowel sounds auscultated in all four quadrants suggest that gastrointestinal motility is present. This is not a priority finding and does not indicate an urgent complication.

E. Hgb: A hemoglobin level of 7 g/dL is critically low and consistent with significant blood loss. This value requires immediate follow-up, likely including blood transfusion and identification of the bleeding source.

F. Heart rate: A heart rate of 118/min reflects a compensatory response to hypotension or blood loss. Tachycardia in this setting is a key sign of circulatory compromise and must be addressed immediately.

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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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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