Based on the client's vital signs, what is the appropriate nursing action?
Contact the health care provider.
Activate the Rapid Response Team.
Provide teaching about relaxation techniques.
Complete an assessment of airway and respiratory status.
The Correct Answer is D
A. While notifying the provider may eventually be necessary, the immediate priority is to assess the client’s respiratory status to determine the severity of hypoxia or respiratory distress.
B. The client is showing early signs of respiratory compromise (tachycardia, tachypnea, labored breathing, SpO2 91%) but is not yet in imminent life-threatening instability that would automatically trigger a rapid response.
C. Anxiety may be present, but it is secondary to the physiologic problem. Relaxation alone does not address hypoxemia or increased work of breathing.
D. The client demonstrates tachycardia, labored respirations, and low oxygen saturation despite supplemental oxygen. The first nursing action is a focused assessment of airway, breathing, and oxygenation to identify causes such as obstruction, retained secretions, or hypoventilation. This assessment guides immediate interventions such as suctioning, oxygen adjustment, or positioning, which are critical before escalating care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administering stress ulcer prophylaxis(such as a proton pump inhibitor or H2 blocker) is a component of VAP prevention bundles, as gastric acid suppression reduces the risk of aspiration-related pneumonia. This statement is correct and does not indicate misunderstanding.
B. Elevating the head of the bed 30–45°is a key VAP prevention measure, as it decreases risk of aspiration of gastric contents. This statement demonstrates proper understanding.
C. Continuous deep sedation is not recommendedfor VAP prevention. Over-sedation increases immobility, delays weaning, and increases the risk of VAP. The preferred practice is daily sedation interruption or light sedation, allowing assessment of readiness for weaning and reducing complications. This statement indicates the family needs additional teaching about sedation practices.
D. Low-dose anticoagulation (e.g., heparin) is used for venous thromboembolism (VTE) prophylaxisin mechanically ventilated patients and is part of standard critical care bundles. It does not directly prevent VAP but is appropriate care.
Correct Answer is ["A","B","C","E"]
Explanation
A. This is above 100.4°F, indicating fever and satisfying the SIRS criterion for abnormal temperature. Fever occurs as a response to cytokine releaseduring systemic inflammation or infection.
B. Heart rate greater than 90 beats/min meets the SIRS criterion. Tachycardia occurs in early SIRS as a compensatory response to maintain cardiac outputin the presence of systemic inflammation or relative hypoperfusion.
C. This exceeds 20 breaths/min and meets the SIRS criterion for tachypnea. Increased respiratory rate is an early compensatory mechanism to improve oxygen delivery to tissues and eliminate CO₂ during systemic inflammation.
D. This is within normal limits. Blood pressure is not part of SIRS criteria, although hypotension can develop later in sepsis progression. A normal BP does not rule out SIRS.
E. Elevated WBC count indicates leukocytosis, meeting the SIRS criterion. This reflects the body’s immune response to infection or systemic inflammation.
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