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 C
Explanation
Choice A reason: This is incorrect. Chronic pain is not a type of pain, but a duration of pain. Chronic pain is pain that lasts longer than six months, regardless of the cause or location. It can affect the patient's physical and mental health, as well as their quality of life.
Choice B reason: This is incorrect. Psychogenic pain is not a type of pain, but a source of pain. Psychogenic pain is pain that is caused or influenced by psychological factors, such as stress, anxiety, depression, or trauma. It can affect any part of the body, but it is not related to the patient's heart attack.
Choice C reason: This is correct. Referred pain is pain that is felt in a different location from the actual source of pain. It occurs when the nerve fibers from different parts of the body converge in the spinal cord or brain. The patient's pain is down his left arm rather than in his chest because the heart and the arm share some nerve pathways.
Choice D reason: This is incorrect. Peripheral pain is pain that is caused by damage or dysfunction of the peripheral nervous system, which consists of the nerves outside the brain and spinal cord. It can cause sensations of numbness, tingling, burning, or shooting pain in the affected area. It is not related to the patient's heart attack.
Correct Answer is B
Explanation
Choice A reason: This is an incorrect choice because temperature, pulse, and blood pressure are not the most important vital signs for a patient who is experiencing shortness of breath. Temperature is not directly related to respiratory function, and pulse and blood pressure can be affected by other factors, such as anxiety or medication.
Choice B reason: This is the correct choice because pulse, respirations, and oxygen saturation are the most important vital signs for a patient who is experiencing shortness of breath. Pulse reflects the heart rate and rhythm, which can be altered by respiratory distress. Respirations reflect the rate and depth of breathing, which can indicate the severity of the condition. Oxygen saturation reflects the percentage of hemoglobin that is bound with oxygen, which can indicate the adequacy of oxygenation.
Choice C reason: This is an incorrect choice because temperature, pulse, and respirations are not the most important vital signs for a patient who is experiencing shortness of breath. Temperature is not directly related to respiratory function, and respirations alone do not provide enough information about the oxygenation status of the patient.
Choice D reason: This is an incorrect choice because respirations, blood pressure, and pain are not the most important vital signs for a patient who is experiencing shortness of breath. Blood pressure can be affected by other factors, such as anxiety or medication, and pain is a subjective symptom that can vary from person to person. Oxygen saturation is a more objective and reliable indicator of oxygenation than pain.
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