A nurse is caring for a group of clients who need positioning. Which client should the nurse prioritize?
A client with edematous lower extremities.
A client who has discomfort.
A client who reports dyspnea.
A client with an order to turn every 2 hours.
The Correct Answer is C
A. A client with edematous lower extremities: Edema requires positioning to promote venous return and reduce swelling, but it does not pose an immediate threat to oxygenation or life. While important, it is lower priority compared with acute respiratory compromise.
B. A client who has discomfort: Discomfort is important to address to maintain comfort and prevent agitation, but it is a lower priority than airway or breathing concerns. Pain management can be incorporated after addressing urgent physiologic needs.
C. A client who reports dyspnea: Dyspnea indicates impaired oxygenation and potential respiratory compromise. Prioritizing this client aligns with the ABC (Airway, Breathing, Circulation) principle, as maintaining adequate oxygenation is life-sustaining and requires immediate intervention.
D. A client with an order to turn every 2 hours: Scheduled turning prevents skin breakdown and pressure injuries but is a preventive measure. It is not more urgent than addressing a client experiencing dyspnea, which poses an immediate risk to safety and health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The visitor is wearing gloves, gown and a mask while in the room: This indicates proper use of standard and droplet precautions for a client with meningitis. Full personal protective equipment (PPE) helps prevent transmission of infectious agents. This demonstrates adherence to infection control guidelines.
B. The visitor is wearing only gloves while feeding the client in the room: Meningitis, particularly bacterial forms, is transmitted via respiratory droplets. Gloves alone do not protect against inhalation or contact with contaminated secretions. Inadequate PPE increases the risk of infection for the visitor and is a significant concern.
C. The visitor cleaned their hands when entering and leaving the room: Proper hand hygiene reduces the risk of transmitting pathogens to or from the client. Handwashing or using hand sanitizer is a key infection control measure. This practice supports patient and visitor safety.
D. The visitor removed their protective gear before leaving the room: Removing PPE before exiting the room is appropriate to prevent contamination of the external environment. Correct doffing of gear is essential to minimize spread of infectious agents.
Correct Answer is B
Explanation
A. Sit the client up in High Fowler's: Elevating the head of the bed can improve lung expansion and oxygenation, but it does not immediately address the critically low respiratory rate and oxygen saturation. This action is supportive but not the highest priority.
B. Call the rapid response team: A respiratory rate of 6 breaths per minute and oxygen saturation of 71% indicate severe hypoxemia and impending respiratory failure. Immediate activation of the rapid response team ensures rapid, coordinated intervention to prevent cardiac or neurologic compromise. Life-threatening instability requires prompt action.
C. Monitor respiratory rate and depth: Ongoing assessment is important, but monitoring alone does not intervene in a life-threatening situation. The client’s condition is critical, and delaying active intervention could result in deterioration. Assessment must be accompanied by emergency response.
D. Prepare for possible intubation: Preparation for intubation is appropriate, but initiating the rapid response team first ensures timely support, equipment, and personnel are available. Immediate coordination is required before advanced procedures.
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