The nurse is performing morning care for a patient who sustained a fractured pelvis and bilateral femur fractures yesterday in a motorcycle collision. The patient complains of shortness of breath. Assessment reveals audible wheezes and oxygen saturation of 76%. What action should the nurse take first?
Explain the patient's change in status to his family
Establish a peripheral intravenous line
Raise patient to High Fowlers position
Inform the charge nurse
The Correct Answer is C
A. Explaining the situation to the family is important, but it is not a priority when the patient is in respiratory distress.
B. Establishing an IV line may be necessary later for treatment, but it does not immediately address the low oxygen saturation or respiratory compromise.
C. Raising the patient to a High Fowler’s position helps to maximize lung expansion and improve oxygenation, making it the first and most immediate action.
D. Notifying the charge nurse is appropriate after the nurse takes action to stabilize the patient’s airway and breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The CPM machine settings should be controlled by healthcare providers or according to prescribed protocols. Patients should not adjust speed or flexion angle independently, as improper settings can cause injury or impede healing.
B. This statement shows humor but does not indicate misunderstanding of CPM use.
C. Finding the motor noise soothing is acceptable and does not indicate a need for further teaching.
D. Allowing the knee to rest at night is appropriate; CPM use is typically during the day or as directed.
Correct Answer is D
Explanation
A. Delayed fine-motor development is not typically an early or defining feature of Duchenne's muscular dystrophy (DMD); gross motor delays are more characteristic.
B. In DMD, the calf muscles may appear enlarged (pseudohypertrophy)due to fat and connective tissue replacing muscle, not true atrophy in early stages.
C. Holding onto furniture is more characteristic of toddlers with normal or delayed gross motor development, not specific to DMD.
D. Frequent falls and clumsinessare hallmark early signsof DMD, reflecting progressive muscle weakness, especially in the pelvic and thigh muscles.
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