The nurse assists with care of a confused patient who presents to the emergency department with stroke symptoms. Vital signs are blood pressure 174/100 mm Hg. pulse 64 beats per minute, and SpO2 88% on room air. Which nursing intervention is priority?
Obtain an electrocardiogram (ECG) exam
Obtain intravenous access
Administer 2 L of oxygen per nasal cannula
Obtain a rectal temperature
The Correct Answer is C
A. Obtain an electrocardiogram (ECG) exam: While an ECG is important to assess cardiac status, it is not the immediate priority compared to addressing the low oxygen saturation.
B. Obtain intravenous access: IV access is important for administering medications and fluids but does not take precedence over addressing hypoxia.
C. Administer 2 L of oxygen per nasal cannula: This is correct. The priority is to improve oxygenation since hypoxia can exacerbate neurological damage in a stroke patient. An SpO2 of 88% is low and requires immediate correction to prevent further complications.
D. Obtain a rectal temperature: Temperature assessment is not as urgent as addressing the immediate need for oxygen to improve SpO2 levels.
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Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
A. Reducing risk for fall: Patients with fractures are at higher risk for falls, which can exacerbate their injuries or cause new ones. Ensuring the environment is safe and assisting with mobility can reduce this risk.
B. Healing the surrounding tissue: While important, the primary focus in the acute phase is stabilizing the fracture itself. Healing surrounding tissue is more of a long-term goal and indirectly supported by proper fracture management.
C. Alignment of the bone: Proper alignment is crucial for healing. It ensures that the bone ends are in the correct position to heal properly and reduces the risk of complications such as malunion.
D. Immobilization of the leg: Immobilization is necessary to maintain bone alignment and prevent further injury or displacement of the fracture.
E. Preventing pain: Pain management is a fundamental aspect of patient care for fractures, as it not only provides comfort but also aids in compliance with treatment and rehabilitation.
Correct Answer is A
Explanation
A. Uric acid: Elevated uric acid levels are the hallmark of gout and are used to monitor and diagnose the condition. Managing uric acid levels is crucial to prevent gout attacks.
B. Blood urea nitrogen: This is more related to kidney function and not directly relevant to gout.
C. Creatinine: Also related to kidney function. While kidney function is important in gout patients, uric acid levels are more directly related to gout management.
D. Cholesterol: High cholesterol is a cardiovascular risk but is not directly related to gout. Monitoring cholesterol is important but not the primary focus for gout management.
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