A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first?
A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89%
A client who has multiple sclerosis and reports ataxia and vertigo
A client who has left-sided paralysis and slurred speech from a prior stroke
A client who has thrombocytopenia and reports a nosebleed
The Correct Answer is A
Choice A Reason:
A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% is correct. The nurse should attend to the client with chronic obstructive pulmonary disease and an oxygen saturation of 89% first. Oxygen saturation levels below 90% indicate significant hypoxemia and potential respiratory distress. The client with COPD is at risk for further worsening of their condition due to inadequate oxygenation. Therefore, addressing this client's low oxygen saturation is a priority to ensure their respiratory status is stabilized.
Choice B Reason:
A client who has multiple sclerosis and reports ataxia and vertigo is incorrect. While these symptoms need assessment and care, they are not indicative of an immediate life-threatening situation.
Choice C Reason:
A client who has left-sided paralysis and slurred speech from a prior stroke is incorrect., While this client requires ongoing care, the immediate concern is lower in priority compared to addressing severe hypoxemia.
Choice D Reason:
A client who has thrombocytopenia and reports a nosebleed is incorrect. Although a nosebleed can be concerning due to thrombocytopenia, it is not as immediately critical as addressing severe hypoxemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Hct 42% is not appropriate. This haematocrit value is within the normal range (usually around 36-46% for females and 38-50% for males).
Choice B reason:
WBC count 8,000/mm3 is not appropriate. This white blood cell count is within the normal range (typically around 4,500 to 11,000/mm3).
Choice C reason:
INR of 1.6 An INR (International Normalized Ratio) of 1.6 indicates that the client's blood clotting time is prolonged, which means that they might have a decreased ability to form blood clots. This could pose a significant risk during surgery, as proper blood clotting is important to prevent excessive bleeding. The surgeon needs to be aware of this result to determine if any adjustments to the surgical plan or preoperative medications are necessary to ensure the client's safety.
Choice D reason:
Platelets 95,000/mm3 is not appropriate This platelet count is slightly lower than the normal range (typically around 150,000 to 450,000/mm3), but it might not be low enough to be immediately concerning, especially if the client doesn't have a history of bleeding disorders. However, it's still important for the surgical team to be aware of this value.
Correct Answer is B
Explanation
Choice A reason:
Bradycardia is incorrect. Bradycardia refers to a slow heart rate, and while anaemia can lead to an increased heart rate (tachycardia) as the body tries to compensate for the decreased oxygen levels, it is not typically associated with bradycardia.
Choice B reason:
Headache Anaemia is a condition characterized by a decreased number of red blood cells or a decrease in the amount of haemoglobin in the blood, leading to reduced oxygen-carrying capacity. This can result in decreased oxygen delivery to various tissues and organs, including the brain. As a result, clients with anaemia often experience symptoms such as fatigue, weakness, and headaches.
Choice C reason:
Flushed skin colour - Anaemia is more likely to cause paleness of the skin (pallor) due to the decreased haemoglobin levels, rather than flushed skin colour.
Choice D reason:
Heat intolerance - Heat intolerance is not a typical symptom of anaemia. It might be seen in conditions affecting the thyroid or related to hormonal imbalances, but it is not directly related to anaemia.
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