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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:
A. Provide finger food at mealtime: Clients with dementia often have difficulty using utensils due to declining motor and cognitive function. Offering finger foods supports independence and helps ensure adequate nutritional intake by simplifying the eating process.

B. Give detailed directions when addressing the client: Detailed instructions can be overwhelming and difficult to process for individuals with dementia. Clear, simple, one-step directions are more effective in promoting understanding and cooperation.

C. Use written signs to redirect the client: As dementia progresses, the ability to read and comprehend written information typically declines. Visual or verbal redirection is more effective for guiding behavior in most clients with moderate to severe dementia.

D. Seat the client at a large table for meals: A large table with many people can create a distracting and overstimulating environment. Smaller, quieter settings help the client focus on eating and reduce agitation during meals.

A. A pearly, waxy nodule B. An irregular border on a variegated-colored lesion C. A firm, nodular, crusty, or ulcerated lesion D. A weeping vesicle

Correct Answer is A

Explanation

Rationale:
A. A pearly, waxy nodule: This is the classic presentation of basal cell carcinoma. These lesions often appear as small, shiny, flesh-colored or pink nodules with a translucent or pearly surface and may have visible blood vessels. They are slow-growing and rarely metastasize.

B. An irregular border on a variegated-colored lesion: This description is more indicative of malignant melanoma, which often appears as an asymmetric lesion with uneven borders and multiple colors, including black, brown, red, or white.

C. A firm, nodular, crusty, or ulcerated lesion: These characteristics are more commonly associated with squamous cell carcinoma, which tends to be more aggressive and can metastasize if untreated.

D. A weeping vesicle: This finding is consistent with inflammatory skin conditions such as contact dermatitis or eczema, not basal cell carcinoma. These vesicles are usually associated with allergic or irritant reactions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is caring for a client who has dementia. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the client's skin?

Correct Answer is A

Explanation

A nurse is planning care for a client who is receiving intermittent IV fluids via a peripherally inserted central catheter (PICC). Which of the following information should the nurse include in the client's plan of care?

A nurse is assessing a group of clients. For which of the following clients should the nurse make a referral to palliative care?

A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse identify as a manifestation of this syndrome?

A nurse is assessing an older adult client who is receiving 2 units of packed RBCs. Which of the following manifestations should indicate to the nurse that the client is experiencing circulatory overload?

A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?

A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurse's priority?

A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of type 1 diabetes?