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 A
Explanation
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 CReason:
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 DReason:
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.
Correct Answer is A
Explanation
Choice A reason:
Confirming the correct position of the line by obtaining a blood sample is appropriate. Inserting a central venous catheter is a procedure that involves placing a catheter into a large vein, typically in the neck, chest, or groin. Confirming the correct placement is crucial to prevent complications such as pneumothorax (lung collapse) or catheter misplacement.
Choice B reason:
Instructing the client to cough as the catheter is inserted is not a standard practice during central venous catheter insertion and could lead to unnecessary complications.
Choice C reason:
Placing the head of the client's bed lower than the foot (Trendelenburg position) is not a standard practice during central venous catheter insertion and would not be helpful for this procedure.
Choice D reason:
Cleansing the site with hydrogen peroxide is not the recommended method for central venous catheter insertion. Typically, a sterile technique and appropriate antiseptic solution are used to reduce the risk of infection.
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