A nurse is caring for a patient who is experiencing shortness of breath and has low oxygen saturation levels. According to Maslow's hierarchy of needs, what should be the nurse's first action?
Administer oxygen therapy to improve oxygen saturation levels
Provide emotional support to the patient.
Discuss the patient's concerns about their safety in the hospital
Assist the patient in meeting their self-actualization needs
The Correct Answer is A
A. Administer oxygen therapy to improve oxygen saturation levels: According to Maslow’s hierarchy, physiologic needs such as oxygenation take highest priority. Hypoxemia compromises cellular metabolism and can rapidly become life-threatening if not corrected. Immediate oxygen therapy supports airway and breathing, making it the nurse’s first action.
B. Provide emotional support to the patient: Emotional reassurance addresses psychosocial needs, which are important but secondary to physiologic stability. A patient experiencing shortness of breath requires correction of oxygen imbalance before anxiety can be effectively managed. Psychological support is more effective once oxygenation improves.
C. Discuss the patient's concerns about their safety in the hospital: Safety concerns fall under Maslow’s safety and security needs. While relevant, these needs are prioritized after physiologic needs such as adequate oxygen delivery. Addressing safety without stabilizing breathing places the patient at continued risk.
D. Assist the patient in meeting their self-actualization needs: Self-actualization represents the highest level of Maslow’s hierarchy and is only addressed after all basic and psychological needs are met. A patient with respiratory compromise is not physiologically stable enough for this level of intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Stage II: Stage II pressure injuries involve partial-thickness skin loss with exposed dermis. The injury may present as a blister, shallow ulcer, or abrasion. Since the skin in this case is intact, it does not meet Stage II criteria.
B. Stage IV: Stage IV pressure injuries are full-thickness tissue losses with exposed bone, tendon, or muscle. This severe stage is accompanied by extensive tissue damage, which is not present in this scenario.
C. Stage III: Stage III injuries involve full-thickness skin loss with damage or necrosis of subcutaneous tissue. The injury may extend down to, but not through, underlying fascia. The intact skin observed here does not qualify as Stage III.
D. Stage I: Stage I pressure injuries are characterized by non-blanchable erythema of intact skin, usually over a bony prominence. This is the earliest stage and indicates localized tissue damage without loss of skin integrity, matching the scenario described.
Correct Answer is D
Explanation
A. Infectious agent: While targeting pathogens is important, nurses typically do not directly eliminate all infectious organisms in the environment. Strategies such as hand hygiene and aseptic technique focus on preventing access rather than eradicating microbes entirely.
B. Mode of transmission: Interventions like hand hygiene, wearing gloves, and using sterile technique reduce transmission, but in this scenario, the infection occurred via the catheter. Targeting transmission alone may not fully prevent bloodstream infections.
C. Susceptible host: The patient’s immune status contributes to risk, but modifying inherent susceptibility (age, comorbidities) is not always feasible. Interventions more directly target controllable factors related to infection risk.
D. Portal of entry: The central venous catheter provides a direct pathway for pathogens into the bloodstream. Using strict aseptic technique during insertion and maintenance, proper dressing changes, and catheter care directly addresses this portal, making it the most effective link to target for prevention.
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