The nurse is obtaining morning vital signs and assessing a 64 year old female client who was admitted with community acquired pneumonia over night. The client is sleeping in supine position, however, she is easily arousable, alert and oriented, and reports no complaints at this time. The client's vital signs are: blood pressure 132/68, heart rate 88 beats per minute, respiratory rate 24 breaths per minute. O2 saturation 87% on 2L nasal cannula oxygen. What is the nurse's first priority action?
Begin oxygen via face mask at 5L/min
Call the physician and report vital signs
Raise the head of the bed
Administer albuterol nebulizer as ordered
The Correct Answer is C
A. Increasing oxygen via face mask may be necessary, but raising the head of the bed is the initial priority to improve oxygenation.
B. Reporting vital signs is important, but immediate intervention is needed to address the low oxygen saturation.
C. Raising the head of the bed helps improve lung expansion and oxygenation in pneumonia patients by reducing pressure on the diaphragm.
D. Administering albuterol may be part of the plan, but improving the client's position is the immediate priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
To answer this question, we need to use the formula: D/H x Q = X, where D is the desired dose, H is the dose on hand, Q is the quantity of the drug on hand, and X is the amount to administer. In this case, D is 15 mg, H is 30 mg, Q is 1 mL, and X is unknown. Plugging these values into the formula, we get:
15/30 x 1 = X
0.5 = X
Therefore, the nurse will administer 0.5 mL of codeine to the patient every four hours.
Correct Answer is A
Explanation
A. Incentive spirometry is a technique that helps prevent atelectasis by encouraging deep breathing and lung expansion.
B. Nebulizer medications may be important for respiratory health but do not specifically address the risk of atelectasis.
C. Sequential compression devices are used to prevent deep vein thrombosis and do not directly address atelectasis.
D. A low-fat diet is not directly related to preventing atelectasis; respiratory exercises are more relevant.
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