A nurse is reviewing a patient’s medical record.
After reviewing the medical data, which of the following actions should the nurse plan to take?
Initiate seizure precautions.
Assist the patient to the bathroom.
Keep the patient’s head in a mid position.
Decrease oxygen to 1.5 L/min via nasal cannula.
The Correct Answer is A
Choice A rationale
Without specific patient data, it’s challenging to provide a detailed rationale.
However, initiating seizure precautions could be necessary if the patient’s medical record indicates a history of seizures or a condition that increases the risk of seizures.
Choice B rationale
Assisting the patient to the bathroom is a routine nursing intervention and would not typically be determined based on a review of the patient’s medical record.
Choice C rationale
Keeping the patient’s head in a mid position would depend on the patient’s condition and would not typically be determined based on a review of the patient’s medical record.
Choice D rationale
Decreasing oxygen to 1.5 L/min via nasal cannula would depend on the patient’s oxygen saturation levels and overall respiratory status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Starting chest compressions is not the first action to take when a client’s cardiac monitor shows ventricular tachycardia. While chest compressions are a part of cardiopulmonary resuscitation (CPR), they are not the initial response to ventricular tachycardia.
Choice B rationale
Immediate defibrillation is the priority action when a client’s cardiac monitor shows ventricular tachycardia. Ventricular tachycardia is a life-threatening condition where the heart
beats too fast to effectively pump blood to the body. Defibrillation delivers an electrical shock to the heart, which aims to restore a normal heart rhythm.
Choice C rationale
Providing pulmonary ventilation is not the first action to take when a client’s cardiac monitor shows ventricular tachycardia. While ventilation is important, it is not the immediate priority in this situation.
Choice D rationale
Checking for a palpable pulse is not the first action to take when a client’s cardiac monitor shows ventricular tachycardia. While it is important to assess the client’s pulse, the priority is to restore a normal heart rhythm through defibrillation.
Correct Answer is B
Explanation
Choice A rationale
Wearing a surgical mask when entering the patient’s room is a standard precaution for all healthcare workers, but it may not be sufficient for a patient with severe coughing, night sweats, and blood in the sputum. These symptoms could indicate a contagious disease such as tuberculosis, which requires airborne precautions.
Choice B rationale
Placing the patient in a negative-pressure airflow room is the correct action. This type of room is used for patients who may have airborne infectious diseases. The negative pressure prevents airborne pathogens from escaping the room and infecting others.
Choice C rationale
Keeping a container for soiled linens outside the patient’s door is not the most appropriate action in this situation. While it is important to handle soiled linens properly to prevent the spread of infection, it does not address the potential airborne transmission of pathogens.
Choice D rationale
Remaining within 3 feet of the patient is not the most appropriate action in this situation. If the patient has an airborne infectious disease, healthcare workers should minimize close contact to prevent exposure.
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