The nursing assessment finding that represents the most serious indication of a client's deteriorating oxygenation status is:

pursed-lip breathing.

clubbing of the nails.

cyanosis.

poor skin turgor.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Pursed-lip breathing is a compensatory mechanism to improve oxygenation and is not as severe an indication as cyanosis.

Choice B rationale: Clubbing of the nails is a chronic sign of oxygenation issues but may not be an acute and immediate indication of deterioration.

Choice C rationale: Cyanosis, the bluish discoloration of the skin and mucous membranes, is a serious indication of inadequate oxygenation.

Choice D rationale: Poor skin turgor is not a direct indicator of oxygenation status.

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Correct Answer is D

Explanation

Choice A rationale: Carbon dioxide level is not a direct indicator of the blood's ability to transport oxygen.

Choice B rationale: Surfactant level is not a direct indicator of the blood's ability to transport oxygen; surfactant is related to lung function.

Choice C rationale: Bicarbonate ion level is more related to acid-base balance and not a direct indicator of the blood's ability to transport oxygen.

Choice D rationale: Hemoglobin level provides the most information about the blood's ability to transport oxygen, as hemoglobin carries oxygen to tissues.

A. Place the client in reverse Trendelenburg position B. Administer IV antibiotics STAT C. Use sterile gloves to replace the protruding parts D. Apply a sterile normal saline dressing

Correct Answer is D

Explanation

Choice A rationale: Placing the client in reverse Trendelenburg position is not the first priority; protecting the wound is more critical.

Choice B rationale: Administering IV antibiotics STAT is not the first priority in the presence of evisceration.

Choice C rationale: Using sterile gloves to replace the protruding parts is not the first intervention; covering the wound takes precedence.

Choice D rationale: Applying a sterile normal saline dressing is the first priority to cover and protect the exposed abdominal contents.

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The nursing assessment finding that represents the most serious indication of a client's deteriorating oxygenation status is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which one of the following blood levels would provide the nurse with the most information about the ability of the client's blood to transport oxygen? The:

Correct Answer is D

Explanation

The nurse enters a client's room to find that his abdominal wound has eviscerated. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

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