The nurse is reviewing the female client's medical record.
Complete the following sentence by using the lists of options
The nurse should first address the client’s
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Rationale for correct choices
• Hypoxemia: The client has an oxygen saturation of 88% on room air and 89% on 2 L/min via nasal cannula, which indicates inadequate oxygenation. Hypoxemia is immediately life-threatening if not addressed promptly and takes priority over infection, hyperglycemia, or dehydration. Correcting oxygenation helps prevent tissue hypoxia and supports organ function.
• Oxygen saturation: The oxygen saturation measurement directly reflects the client’s hypoxemic status. Continuous monitoring of oxygen saturation is critical to evaluate the effectiveness of supplemental oxygen therapy and guide adjustments. This parameter is an objective indicator of respiratory compromise and provides the most immediate evidence for urgent intervention.
Rationale for incorrect choices
• Infection: The client has pneumonia evidenced by fever, productive cough with yellow sputum, and elevated WBC count. While infection requires prompt antibiotic therapy, it is not more immediately life-threatening than hypoxemia. Addressing oxygenation takes precedence before managing the underlying infection.
• Type 2 diabetes mellitus: The client’s blood glucose is elevated at 195 mg/dL, reflecting hyperglycemia. Although this requires monitoring and potential insulin therapy, it is not an immediate threat to oxygenation or organ perfusion. Hyperglycemia management is important but secondary to correcting hypoxemia.
• Dehydration: The BUN is slightly elevated at 25 mg/dL, which may indicate mild dehydration. The client is receiving IV fluids to support hydration. While fluid balance should be monitored, dehydration is not the most urgent issue compared with the client’s low oxygen saturation.
• BUN level: BUN elevation provides indirect evidence of fluid status or renal function but does not indicate immediate risk to tissue oxygenation. It is important for ongoing assessment but does not guide the initial urgent intervention.
• Blood glucose: Blood glucose reflects the client’s diabetic status and hyperglycemia. It is important to monitor and manage over time, but it does not provide the immediate evidence of hypoxemia that requires urgent correction.
• WBC count: Elevated WBC indicates infection and systemic inflammation. While this guides antibiotic therapy and monitoring, it does not address the immediate risk posed by hypoxemia. Prompt oxygen therapy takes priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tetany: Calcium is essential for proper neuromuscular function. A deficiency can lead to increased neuromuscular excitability, resulting in muscle spasms, cramps, and tetany, which are hallmark signs of hypocalcemia.
B. Anemia: Anemia is typically related to deficiencies in iron, vitamin B12, or folate, not calcium. While calcium plays roles in other body functions, it is not a direct factor in hemoglobin synthesis or red blood cell production.
C. Kidney stones: Kidney stones are more commonly associated with hypercalcemia or high calcium excretion rather than calcium deficiency. Low calcium intake may actually increase oxalate absorption, but it is not a direct cause of stones.
D. Osteoarthritis: Osteoarthritis is a degenerative joint disease influenced by age, joint stress, and cartilage wear. Calcium deficiency affects bone density (leading to osteoporosis) rather than the cartilage degeneration seen in osteoarthritis.
Correct Answer is C
Explanation
A. Limit each of the client's visitors to 1 hr per day: Visitor restrictions for clients with sealed radiation implants typically focus on limiting cumulative exposure to radiation rather than a strict daily time limit. The exact duration may vary, but monitoring personal exposure is more critical for staff safety.
B. Remove dirty linens from the room after double bagging: For sealed radiation implants, the radioactive source remains contained, and linens are not highly radioactive. Standard precautions are sufficient, so special double-bagging is not required unless the linens are contaminated with bodily fluids.
C. Wear a dosimeter film badge while in the client's room: Staff who care for clients with sealed radiation implants must wear a dosimeter to monitor cumulative radiation exposure. This ensures that occupational safety limits are not exceeded and provides documentation of exposure levels, which is a key safety measure in the plan of care.
D. Ensure family members remain at least 1 m (3.2 feet) from the client: Family members may need limited exposure, but strict distance alone is not sufficient for safety or required for all types of sealed implants. Staff exposure monitoring via dosimeter is more critical, as they spend more time in the room and are at greater risk for cumulative exposure.
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