The patient’s vital signs are as follows: Temperature 97.5 F (36.4 C), Heart rate 104 beats/minute, Respirations 29 breaths/minute, Blood pressure 119/82 mm Hg, Oxygen saturation 89%. Oxygen mask applied.
What should the nurse do next?
Check the patient’s temperature again.
Monitor the patient’s heart rate.
Observe the patient’s breathing.
Check the patient’s blood pressure.
The Correct Answer is C
Choice A rationale:
Checking the patient's temperature again is not a priority at this time. The patient's temperature is within the normal range, and there is no indication that it is the cause of the patient's hypoxia.
Focusing on temperature measurement could delay more crucial interventions to address the patient's breathing difficulty.
Choice B rationale:
While monitoring the patient's heart rate is important, it is not the most immediate priority in this situation. The patient's heart rate is elevated, but it is not dangerously high.
The elevated heart rate is likely a compensatory response to the patient's low oxygen saturation. Addressing the underlying cause of the hypoxia, which is likely respiratory in nature, will also help to stabilize the heart rate.
Choice C rationale:
Observing the patient's breathing is the most important action the nurse can take at this time. The patient's respirations are rapid and shallow, indicating respiratory distress.
This is a serious condition that requires immediate intervention. By observing the patient's breathing, the nurse can assess the severity of the distress and determine the best course of action.
The nurse can observe for signs of increased work of breathing, such as use of accessory muscles, nasal flaring, and retractions. They can also auscultate the lungs to assess for any abnormal breath sounds, such as wheezing or crackles.
This information will help the nurse to determine the underlying cause of the respiratory distress and to initiate appropriate interventions, such as administering oxygen, positioning the patient, or calling for assistance from a respiratory therapist.
Choice D rationale:
Checking the patient's blood pressure is not a priority at this time. The patient's blood pressure is within the normal range. While it is important to monitor the patient's blood pressure, it is not the most immediate concern in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E","F","G"]
Explanation
The correct answer is choiceb. Identify the client using 2 client identifiers,c. Perform hand hygiene,e. Don gloves,f. Check the skin around the face, andg. Assess respiratory function.
Choice A rationale:
Determining if the client needs to go to the bathroom is not directly related to the immediate preparation for oxygen administration. However, it can be considered as part of overall patient comfort and care.
Choice B rationale:
Identifying the client using 2 client identifiers is crucial to ensure the correct patient is receiving the correct treatment, which is a standard safety protocol in healthcare settings.
Choice C rationale:
Performing hand hygiene is essential to prevent the spread of infection and maintain a sterile environment.
Choice D rationale:
Brushing the client’s teeth is not a necessary step before applying a simple face mask for oxygen administration. It is more related to general oral hygiene.
Choice E rationale:
Donning gloves is important to protect both the nurse and the patient from potential contamination and infection.
Choice F rationale:
Checking the skin around the face is important to ensure there are no existing sores or irritations that could be exacerbated by the mask.
Choice G rationale:
Assessing respiratory function is critical to determine the patient’s baseline respiratory status and to monitor the effectiveness of the oxygen therapy.
Correct Answer is D
Explanation
Rationale for Choice A: Dysrhythmia
There is no information in the question stem to suggest that the patient is experiencing a dysrhythmia.
Dysrhythmias are abnormal heart rhythms that can be caused by a variety of factors, including heart disease, electrolyte imbalances, and medications.
While it is possible that the patient could develop a dysrhythmia as a complication of pneumonia, there is no evidence to support this in the given information.
Additionally, enalapril, which the patient is taking for hypertension, is not typically associated with an increased risk of dysrhythmias.
Rationale for Choice B: Toxicity
There is no information in the question stem to suggest that the patient is experiencing toxicity.
Toxicity can be caused by a variety of substances, including medications, drugs, and environmental toxins.
While it is possible that the patient could develop toxicity as a complication of pneumonia, there is no evidence to support this in the given information.
Additionally, the patient's medication regimen of enalapril and a multivitamin is not typically associated with an increased risk of toxicity.
Rationale for Choice C: Anemia
There is no information in the question stem to suggest that the patient is anemic.
Anemia is a condition in which there is a decreased number of red blood cells or hemoglobin in the blood.
While it is possible that the patient could develop anemia as a complication of pneumonia, there is no evidence to support this in the given information.
Additionally, the patient's surgical history of adenoid removal and a fractured tibia is not typically associated with an increased risk of anemia.
Rationale for Choice D: Pneumonia
The patient is a 51-year-old male with a diagnosis of pneumonia.
Pneumonia is an infection of the lungs that can be caused by bacteria, viruses, or fungi.
The patient's symptoms, such as cough, fever, and difficulty breathing, are all consistent with a diagnosis of pneumonia.
Additionally, the patient's medical history of hypertension does not rule out pneumonia, and in fact, some studies have shown that hypertension may be a risk factor for developing pneumonia.
Therefore, pneumonia is the most likely condition that the patient has based on the information provided.
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