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A nurse is caring for a patient who reports fatigue and had a syncopal episode at home.

Exhibits

The nurse has completed an assessment on the client after the syncopal episode. Complete the following sentence by using the list of options.

The nurse should first address the patient’s

followed by the patient’s

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Answer: The nurse should first address the patient’s oxygen saturation followed by the patient’s hypotension.

Rationale:

1st Priority: Oxygen Saturation → The client’s oxygen saturation has dropped to 88% on room air, which is below the expected range (typically ≥95% in healthy individuals). Hypoxia must be addressed immediately to prevent further complications. The nurse should apply supplemental oxygen and reassess respiratory status.

2nd Priority: Hypotension → The client’s blood pressure has dropped to 94/59 mmHg, which is significantly lower than the earlier reading of 102/76 mmHg. This may contribute to dizziness and syncope. The nurse should monitor for signs of hemodynamic instability, assess for ongoing blood loss (related to heavy menstrual bleeding), and anticipate interventions such as IV fluids or further evaluation for anemia-related hypotension.


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Related Questions

Correct Answer is A

Explanation

A. Loosen the patient's restrictive clothing – This helps prevent airway obstruction and allows for better chest expansion during the seizure.

B. Open the patient’s jaws to insert an oral airway – Never attempt to force open the mouth during a seizure, as it can cause injury.

C. Restrain the patient to prevent injury – Restraining can cause further harm and should be avoided. Instead, clear the area around the patient to prevent injury.

D. Place patient in high-Fowler’s position – The patient should be placed in a side-lying position to prevent aspiration, not high-Fowler’s.

Correct Answer is D

Explanation

A. Eat plenty of fresh fruits and vegetables. – Incorrect. Raw fruits and vegetables can harbor bacteria, increasing the risk of infection for a patient with neutropenia.

B. Take temperature weekly. – Incorrect. Patients with neutropenia should check their temperature daily, as fever may be the first sign of infection.

C. Perform mild exercise, such as gardening. – Incorrect. Gardening exposes the patient to soilborne fungi and bacteria, which can be harmful.

D. Avoid crowds. – Correct Answer. Neutropenic patients are highly susceptible to infections, so avoiding crowds helps reduce the risk of exposure to contagious illnesses.

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