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. Treatment for osteomyelitis typically requires a prolonged course of antibiotics, usually around 4 to 6 weeks, to ensure complete eradication of the infection.
B. Six months is longer than the usual duration and generally reserved for complicated or chronic infections.
C. Five days is too short to effectively treat osteomyelitis and would likely lead to treatment failure.
D. Three months is longer than usual and may be considered in some severe cases, but 6 weeks is the standard duration.
Correct Answer is A
Explanation
A. Myasthenia gravis is an autoimmune disorder where antibodies attack acetylcholine receptors at the neuromuscular junction, leading to muscle weakness.
B. Inability of basal ganglia to produce sufficient dopamine is related to Parkinson’s disease, not myasthenia gravis.
C. A post-viral illness with ascending paralysis describes Guillain-Barré syndrome.
D. Loss of the myelin sheath surrounding peripheral nerves occurs in diseases like multiple sclerosis and peripheral neuropathies, not myasthenia gravis.
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