The nurse is caring for a patient with the following vital signs:
Temperature: 98.9°F
Pulse: 94
Respirations: 20
Blood pressure: 144/94
Pulse oximetry: 94%
What is the priority action of the nurse?
Ask the patient about his usual blood pressure results.
Apply a cool washcloth to the patient's forehead.
Administer oxygen at 2 L/minute via nasal cannula.
Document the findings in the patient's medical record.
The Correct Answer is C
Choice A reason: This is an incorrect choice because asking the patient about his usual blood pressure results is not a priority action. The patient's blood pressure is elevated, but not dangerously high. The nurse should monitor the blood pressure and report any significant changes to the physician, but this is not an urgent intervention.
Choice B reason: This is an incorrect choice because applying a cool washcloth to the patient's forehead is not a priority action. The patient's temperature is normal, and there is no indication of fever or heat stroke. The nurse should ensure the patient is comfortable and hydrated, but this is not an urgent intervention.
Choice C reason: This is the correct choice because administering oxygen at 2 L/minute via nasal cannula is a priority action. The patient's pulse oximetry is low, indicating hypoxia or inadequate oxygenation of the tissues. The nurse should provide supplemental oxygen to improve the patient's oxygen saturation and prevent further complications.
Choice D reason: This is an incorrect choice because documenting the findings in the patient's medical record is not a priority action. The nurse should document the patient's vital signs and any interventions performed, but this is not an urgent intervention. The nurse should prioritize the patient's safety and well-being over documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: This is incorrect. Turning on the television to drown out noise from other patients can worsen the sensory overload by adding more auditory stimulation. The patient may prefer a quiet and calm environment.
Choice B reason: This is correct. Instituting a unit-wide quiet time at 10:00 p.m. each night can benefit the patient by reducing the noise level and promoting rest and relaxation. The patient may sleep better and feel less agitated.
Choice C reason: This is correct. Reducing the number of visitors to the patient’s room can benefit the patient by minimizing the social and emotional demands and allowing the patient to have some privacy and personal space. The patient may feel less overwhelmed and more comfortable.
Choice D reason: This is correct. Providing a dedicated period of rest time each afternoon can benefit the patient by giving the patient a break from the sensory input and activities of the day. The patient may use this time to meditate, listen to soothing music, or do other calming activities.
Choice E reason: This is correct. Coordinating therapies and tests with other departments and providers can benefit the patient by avoiding unnecessary duplication or interruption of services and ensuring a smooth and consistent care plan. The patient may feel less stressed and more confident.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because the apical pulse is the most accurate measurement of the heart rate and rhythm. Digoxin is a cardiac medication that affects the heart rate and can cause arrhythmias. Therefore, the nurse should use the apical pulse to monitor the patient's response to the medication.
Choice B reason: This is an incorrect choice because the carotid pulse is not the best site to measure the heart rate before administering digoxin. The carotid pulse is located in the neck and can be affected by external factors such as pressure or movement. The carotid pulse is also not recommended for routine use because it can stimulate the vagus nerve and lower the heart rate.
Choice C reason: This is an incorrect choice because the radial pulse is not the best site to measure the heart rate before administering digoxin. The radial pulse is located in the wrist and can be affected by peripheral factors such as circulation or temperature. The radial pulse can also be inaccurate or irregular if the patient has an arrhythmia.
Choice D reason: This is an incorrect choice because the brachial pulse is not the best site to measure the heart rate before administering digoxin. The brachial pulse is located in the upper arm and can be affected by arm position or blood pressure. The brachial pulse is also not as reliable as the apical pulse for detecting changes in the heart rate and rhythm.
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