A nurse is caring for a patient who reports fatigue and had a syncopal episode at home.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. The GCS assesses level of consciousness based on eye-opening, verbal response, and motor response.
B. Incorrect. Reflex activity is assessed separately using neurological reflex tests.
C. Incorrect. Sensory involvement is evaluated through different neurological exams, not the GCS.
D. Incorrect. Cognitive ability assessment requires specialized tests, such as the Mini-Mental State Examination (MMSE).
Correct Answer is C
Explanation
A. Incorrect. Regular insulin should be given before a meal to allow time for onset; giving it after eating delays its effect, increasing hyperglycemia risk.
B. Incorrect. Administering regular insulin after breakfast is inappropriate as it may not align with meal-related glucose spikes.
C. Correct. Regular insulin has an onset of 30 minutes. Administering it at 0730 ensures optimal timing for glucose control when breakfast is eaten at 0800.
D. Incorrect. Giving insulin too early (at 0700) increases the risk of hypoglycemia before food intake.
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