The practical nurse (PN) is caring for a client with a fractured left hip. The client develops tachypnea and deterioration in mental status. Which nursing intervention has the highest priority?
Perform an arterial stick to obtain a PaO2 level.
Obtain vital signs, including oxygen saturation.
Start oxygen at 2 liters nasal cannula.
Assess pain level and last pain medication given.
The Correct Answer is C
A. Performing an arterial stick to obtain a PaO2 level is important for diagnostic purposes but does not address the immediate need to improve oxygenation.
B. Obtaining vital signs, including oxygen saturation, is important but should follow the initiation of oxygen therapy to address the immediate threat to the client’s respiratory status.
C. Starting oxygen at 2 liters nasal cannula is the highest priority intervention to immediately improve the client’s oxygenation status and address the acute symptoms of tachypnea and altered mental status.
D. Assessing pain level and last pain medication given is important but secondary to addressing the client's acute respiratory symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
The child’s symptoms—drowsiness, thick yellow secretions, low respiratory rate, and fever—along with the chest x-ray showing consolidation consistent with pneumonia, indicate that he is experiencing respiratory insufficiency. Respiratory insufficiency occurs when the respiratory system fails to meet the body's oxygen needs or remove carbon dioxide effectively.
Actions to Take:
1. Perform oropharyngeal suctioning
Suctioning is necessary to clear the thick yellow secretions that can obstruct the airway and contribute to respiratory insufficiency. It helps maintain a patent airway and improves the child's ability to breathe.
2. Provide humidified supplemental oxygen
Humidified oxygen helps to maintain airway moisture and improve oxygenation, which is critical for managing respiratory insufficiency. It can also help loosen secretions and alleviate symptoms related to pneumonia.
Parameters to Monitor:
1. Oxygen Saturation
Monitoring oxygen saturation is essential to assess the effectiveness of supplemental oxygen and interventions for respiratory insufficiency. Low oxygen saturation indicates that the respiratory system is not meeting the oxygen demands of the body.
2. Temperature
Temperature monitoring is important to assess the effectiveness of fever management and to monitor for potential worsening of the infection. Elevated temperature can exacerbate respiratory insufficiency and indicate ongoing infection.
Correct Answer is B
Explanation
A. A warm sleeping environment may exacerbate pruritus by increasing skin dryness and irritation. Cool, comfortable environments are generally better for clients with pruritus.
B. Keeping fingernails trimmed short helps prevent skin damage and infection caused by scratching. This is a practical and effective measure to manage pruritus.
C. Discouraging the use of skin lubricants is not advisable as they can help soothe and moisturize dry, itchy skin. Emollients and moisturizers are often recommended to manage pruritus.
D. Advising against any type of tub bath is not necessary. Instead, the use of lukewarm baths with added colloidal oatmeal or other soothing agents can help reduce pruritus.
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