Based on the physical exam findings, which assessment indicates the client’s condition is worsening?
Cyanotic mucous membranes and oxygen saturation of 84% on 3 L nasal cannula.
Diffuse wheezing auscultated throughout lung fields and hand tremor present.
Blood pressure of 168/90 mm Hg and heart rate of 98/min.
Clear rhinorrhea visible and skin warm and dry.
The Correct Answer is A
Choice A rationale
Cyanotic mucous membranes and oxygen saturation of 84% indicate severe hypoxemia. Normal oxygen saturation is 95–100%. The cyanosis suggests inadequate tissue oxygenation, requiring immediate intervention to prevent respiratory failure.
Choice B rationale
Diffuse wheezing and tremors may signify severe airway obstruction or beta-agonist overuse. While concerning, these findings are not as immediately life-threatening as hypoxemia and cyanosis.
Choice C rationale
Elevated blood pressure (168/90 mm Hg) and heart rate (98/min) may indicate stress or pain but do not reflect acute life-threatening changes compared to severe hypoxemia.
Choice D rationale
Clear rhinorrhea and warm, dry skin may suggest mild upper respiratory infection. These findings do not indicate imminent danger or severe respiratory compromise compared to hypoxemia and cyanosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Administering antibiotics is crucial for meningitis management but should follow infection control protocols to prevent transmission, aligning with the prioritization of safety in Maslow's hierarchy of needs.
Choice B rationale
Providing analgesics manages symptoms but does not prevent disease spread. Initiating precautions addresses the immediate risk of contagion, which takes precedence in infection control.
Choice C rationale
Initiating droplet precautions minimizes the risk of disease transmission to healthcare providers and others, adhering to infection control standards and being the primary action in meningococcal meningitis.
Choice D rationale
Educating the client is important for understanding the illness, but immediate containment of the infectious agent through precautions is the priority in preventing disease spread.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
A secure grip is important for safety, but it does not directly influence the biomechanical effectiveness of cane use. Teaching specific techniques for effective cane use is a priority in client education.
Choice B rationale
Holding the cane on the stronger side increases stability and reduces the risk of falls by redistributing weight to compensate for the weaker side during ambulation.
Choice C rationale
A slight elbow flexion allows for shock absorption and optimal mechanical leverage while using the cane, minimizing strain on the joints and enhancing control during ambulation.
Choice D rationale
Advancing the cane and weaker leg together ensures coordination and stability by aligning the center of gravity, which helps maintain balance and prevent falls during movement.
Choice E rationale
While a quad cane offers more support, its use is dependent on the client’s condition and specific needs. It is not a universal requirement for all cane users, making it less relevant for general instructions.
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