An older adult client with emphysema, who continues to smoke cigarettes, returns to the medical unit after a physical therapy session, and is short of breath. The nurse notes that the client is lying supine with the head of the bed elevated to 45 degrees. Oxygen is flowing via nasal cannula at 3L/minute. The client's pulse oximetry is 88%, respiratory rate is 14 breaths/minute, and vital signs are stable. Which intervention should the nurse implement?
Administer a prescribed albuterol inhaler.
Assess lung sounds for signs of infection.
Encourage client to initiate a smoking cessation program.
Notify the healthcare provider of the low pulse oximetry value.
The Correct Answer is D
A. Administering a prescribed albuterol inhaler may be appropriate if the client is experiencing bronchospasm or increased airway resistance. However, before giving any medication, the nurse must report and clarify the low oxygen saturation with the healthcare provider, as supplemental oxygen or other interventions may need adjustment.
B. Assessing lung sounds for signs of infection is important for ongoing evaluation, but this is not the immediate priority in a client who is currently hypoxic. Immediate attention to oxygenation takes precedence.
C. Encouraging the client to initiate a smoking cessation program is important for long-term management of emphysema, but it does not address the current acute hypoxemia.
D. Notifying the healthcare provider of the low pulse oximetry value is the most important action. A pulse oximetry of 88% in a client receiving supplemental oxygen indicates hypoxemia and may require prompt intervention, such as adjusting oxygen flow, administering bronchodilators, or further evaluation for complications like infection or exacerbation of chronic obstructive pulmonary disease (COPD). Immediate reporting ensures timely assessment and treatment to prevent respiratory deterioration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Identifying the client’s healthcare power of attorney (POA) is important for legal and consent purposes, especially when the client cannot make decisions independently. However, in the context of an SBAR (Situation, Background, Assessment, Recommendation) communication, this information is not the most urgent. It falls under background or additional information but does not directly address the client’s acute clinical change.
B. Reporting that the client fell at home provides relevant background information for the healthcare provider. It helps contextualize the admission and may guide the evaluation of injuries, but it does not communicate the immediate concern. In SBAR, this would be included under the “Background” section, after the urgent situation is stated.
C. Providing the client’s current medication list is also part of the background information and may help the provider identify potential contributors to the acute change in mental status, such as sedatives, anticholinergics, or polypharmacy. While important, it does not represent the urgent situation requiring immediate attention.
D. Reporting the client’s increasing confusion is the most critical information and should be provided first, under the “Situation” portion of SBAR. Acute confusion in an older adult, especially following a fall, can signal serious complications such as head injury, intracranial bleeding, delirium due to infection, medication-related adverse effects, or metabolic or electrolyte imbalances. Promptly communicating this change allows the healthcare provider to prioritize assessment, order necessary tests, and implement interventions quickly to ensure patient safety. In SBAR, starting with the urgent change in status helps focus the provider’s attention on immediate risks before reviewing the background or assessment details.
Correct Answer is A
Explanation
A. Prostate infections, such as prostatitis, can cause inflammation and irritation of the prostate gland, which can lead to elevated PSA levels. This is an important factor to explain to the client because PSA elevation is not specific to cancer alone; other benign conditions can also increase PSA. Understanding this helps reduce unnecessary anxiety and informs appropriate follow-up testing.
B. Prostatectomy involves surgical removal of the prostate gland. After a complete prostatectomy, PSA levels typically decrease to undetectable levels rather than increase. Therefore, this procedure would not cause elevated PSA.
C. Tobacco use is associated with various cancers and cardiovascular disease but does not directly elevate PSA levels. While smoking has systemic effects, it is not a recognized cause of increased PSA.
D. Alcohol consumption affects liver function and overall health but is not linked to elevated PSA levels. There is no direct correlation between alcohol intake and PSA elevations in prostate screening.
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