After assessing a client with deficits from a spinal cord injury, the nurse identifies the client's 02 saturation is 92%. Which of the following is the best first action by the nurse?

A Anticipate intubation

B Ask client to cough, then inhale and exhale deeply

C Insert an intravenous catheter

D Administer antihypertensives

Answer and Explanation

The Correct Answer is B

Choice A Rationale: Anticipating intubation is not warranted solely based on an O2 saturation of 92% and without further assessment.

Choice B Rationale: Asking the client to cough, then inhale and exhale deeply is an appropriate initial action to improve oxygenation and assess the client's respiratory status.

Choice C Rationale: Inserting an intravenous catheter is unrelated to the client's O2 saturation and would not address the immediate concern.

Choice D Rationale: Administering antihypertensives is not indicated based on the O2 saturation level, and it may not be safe without further assessment.

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Correct Answer is C

Explanation

Choice A Rationale: Measuring the calves for symmetry is not directly related to preventing complications after repositioning.

Choice B Rationale: Palpating the bladder is important for assessing urinary retention but is not the immediate action to prevent complications after repositioning.

Choice C Rationale: Placing a pillow between the knees and ankles is the correct action to prevent complications such as pressure ulcers and skin breakdown when a client is in a side-lying position.

Choice D Rationale: Checking the gag reflex is unrelated to repositioning and preventing complications.

A. Fecal incontinence B. Urinary incontinence C. Inability to smile D. Able to drive to familiar places

Correct Answer is D

Explanation

Choice A Rationale: Fecal incontinence is not typically associated with mild Alzheimer's disease but may occur in later stages.

Choice B Rationale: Urinary incontinence can occur in Alzheimer's disease, but it is not specific to the mild stage.

Choice C Rationale: Inability to smile is not a typical manifestation of Alzheimer's disease but may be related to facial muscle weakness or other factors.

Choice D Rationale: Being able to drive to familiar places is consistent with the early stage of Alzheimer's disease, where clients may still have some independence and ability to perform routine tasks.

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After assessing a client with deficits from a spinal cord injury, the nurse identifies the client's 02 saturation is 92%. Which of the following is the best first action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?

Correct Answer is C

Explanation

The nurse caring for the client with Alzheimer's documents that the client is in the early stage of Alzheimer's. Which findings are consistent with mild Alzheimer's disease?

Correct Answer is D

Explanation

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