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 C
Explanation
A. Gentamicinis typically administered intravenously, not orally, for serious infections like meningitis due to poor oral absorption.
B. Encouraging 3,000 mL of fluidis excessive and inappropriate for a 10-month-old, risking fluid overload.
C. Wearing a maskis an essential infection control measure when caring for an infant with bacterial meningitis, especially meningococcal meningitis, which can be highly contagious and transmitted via respiratory droplets.
D. Forcing neck flexion can cause severe painand is contraindicatedin meningitis, where neck stiffness is a hallmark symptom.
Correct Answer is A
Explanation
- Convert weight to kilograms:
82 lb ÷ 2.2 = 37.27 kg - Calculate safe dose range:
Minimum dose:10 mg × 37.27 kg = 372.7 mg/day
Maximum dose:12 mg × 37.27 kg = 447.24 mg/day
- Compare with ordered dose:
Ordered dose = 500 mg/day
Safe range = 372.7 mg to 447.24 mg/day
→ 500 mg exceeds the maximum safe dose (447.24 mg)
Final Answer:No, the order is not safe.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.