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 D

Explanation

Choice A Rationale: Loosening all of the connections on the vest to assess the skin is not the first priority and may compromise the stability of the halo brace.

Choice B Rationale: Asking about the client's ability to perform range of motion to legs is important but may not be the first priority.

Choice C Rationale: Asking how the client is able to reposition self in bed is important but may not be the first priority.

Choice D Rationale: Assessing the pin sites is the first priority in caring for a client with a halo brace, as complications related to pin site infections or issues can have significant consequences. Pin site care and assessment are crucial to prevent infections and complications.

A. A "He didn't remember the neighbor's name after I introduced them at the picnic" B "He discarded the utility bills but never paid them" B. C "He has been retired for 5 years but keeps talking about how excited he is to start his new job C. D "He forgets he read the newspaper and reads it over all day" D. E "found his car keys in the refrigerator and his shoes in the microwave"

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A Rationale: Forgetting names and faces, especially when previously introduced, can be a sign of memory impairment, which is common in Alzheimer's disease. Choice B Rationale: Neglecting bills and financial responsibilities is a sign of impaired executive function, which can occur in Alzheimer's disease.

Choice C Rationale: Mentioning excitement about starting a new job after retirement is a typical sign of Alzheimer's disease.

Choice D Rationale: Repeatedly forgetting that one has already read the newspaper and reading it again can be a sign of short-term memory loss, a characteristic of Alzheimer's disease.

Choice E Rationale: Placing car keys in unusual places and misplacing items like shoes in unexpected locations can be signs of disorientation and memory problems, which are common in Alzheimer's disease.

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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

The nurse is providing care for a client who was placed in a halo brace 2 days ago because of a spinal cord injury. Which assessment is the first priority of the nurse?

Correct Answer is D

Explanation

A family member arrives with a client indicating that they are concerned that the client is developing Alzheimer's disease. Which of the following items described by the family member are signs of Alzheimer's Disease? Select All that Apply

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

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