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.

Answer and Explanation

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.

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Correct Answer is ["A","D","E"]

Explanation

A. Place the drink where the client can reach from her bed
Placing the drink where the client can easily reach it encourages regular fluid intake. Accessibility is key for clients who may be feeling weak or fatigued, especially when dealing with symptoms of illness like fever and cough. Ensuring that fluids are within reach minimizes barriers to drinking and supports better hydration efforts.
B. Encourage drinks with high sugar content
Drinks with high sugar content are not ideal for promoting adequate fluid intake. High sugar content can worsen symptoms like nausea or dehydration and may lead to increased thirst or gastrointestinal upset, which is counterproductive to encouraging fluid intake. Offering fluids with balanced electrolytes and moderate sugar content is more beneficial.
C. Only offer water or other clear drink
Offering only water or clear drinks can be too restrictive and may not meet the client's preferences or needs. While clear liquids are appropriate, incorporating a variety of fluids can improve hydration and patient satisfaction. It is beneficial to offer options that the client might find appealing.
D. Ask the client what her favorite drink is
Asking the client for her favorite drink engages her in the decision-making process and increases the likelihood of her consuming more fluids. Personal preferences can significantly affect fluid intake, and offering drinks she likes can help in achieving adequate hydration.
E. Offer both hot and cold drinks
Offering both hot and cold drinks can cater to the client’s preferences and provide comfort, which may encourage her to drink more fluids. Variety in temperature can make drinking fluids more appealing, especially if the client is feeling unwell or has specific preferences.
F. Suggest popular drinks like coffee or soda
Suggesting coffee or soda is not recommended due to their diuretic effects and potential for dehydration. Coffee and soda can also interfere with electrolyte balance and are generally not suitable for hydration in a clinical setting where the goal is to address fluid volume deficit

A. Skin turgor. B. Body weight. C. Temperature. D. Blood pressure.

Correct Answer is D

Explanation

A. Skin turgor is important for assessing hydration status, but it is not the most critical factor when preparing for a safe transfer. For an unresponsive client, ensuring stable hemodynamic conditions is more urgent. Blood pressure provides essential information about the client’s circulatory status, which is crucial for assessing the risks associated with the transfer.
B. Body weight is generally used for dosing medications or assessing nutritional status and is not immediately relevant for ensuring a safe transfer of an unresponsive client. Although body weight might be useful in planning the transfer logistics, it does not impact immediate safety concerns.
C. Temperature can indicate infection or other issues but does not directly affect the immediate safety of the transfer process. While monitoring temperature is part of overall care, it is not the most pressing concern during the transfer.
D. Blood pressure is essential to check before the transfer because it reflects the client’s cardiovascular stability. Low or unstable blood pressure might increase the risk of complications during the transfer, such as a sudden drop in blood pressure that could lead to a fall or injury.

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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?

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Naxlex Comprehensive Predictor Exams

Exhibits The practical nurse (PN) would like to encourage the client to take oral fluids so that the IV fluids can eventually be discontinued. Which three strategies would be most effective in getting a client to consume adequate oral fluids?

Correct Answer is ["A","D","E"]

Explanation

The practical nurse (PN) is preparing to transfer an unresponsive client from the bed to a stretcher. Which client data is most important for the PN to obtain before beginning the transfer?

Correct Answer is D

Explanation

In performing a focused assessment, the practical nurse (PN) lifts the client's skin as seen in the photo. Which should the PN do next?

The mother of a young child with eczema asks about the type of clothing that is best for her child's comfort. Which choice should the practical nurse (PN) recommend?

Which foot care instruction is most important for the practical nurse (PN) to reinforce that minimizes a long-term complication for a client who is newly diagnosed with type 2 diabetes mellitus (DM)?

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) obtain a client's vital signs. The PN should intervene when observing the UAP performing which technique?

While the practical nurse (PN) and unlicensed assistive personnel (UAP) are turning a client with an abdominal incision, the client's incision eviscerates. Which task is best for the PN to assign to the UAP?

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