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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?

A.

Perform an arterial stick to obtain a PaO2 level.

B.

Obtain vital signs, including oxygen saturation.

C.

Start oxygen at 2 liters nasal cannula.

D.

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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Related Questions

Correct Answer is B

Explanation

A. Protecting the client's left side during transfers is not directly related to addressing neglect syndrome. Clients with right hemisphere strokes may neglect the left side, but the UAP should be guided to approach from the left to help manage the neglect.
B. Demonstrating to the UAP how to approach the client from the left side helps manage the effects of neglect syndrome. Clients with right hemisphere strokes may not be aware of or may ignore the left side, so approaching from this side can improve the client’s awareness and safety.
C. Observing interactions between the client and family members might provide insights into the client’s condition but is not a direct intervention for managing neglect syndrome. The focus should be on practical strategies to help the client with neglect.
D. Asking the UAP to leave the room and assessing the client for bruising does not address the immediate needs of managing neglect syndrome. The priority is to ensure the client is safely engaged and managed, rather than performing a solitary assessment.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

  1. "MRSA is not that big of a deal."
    No Understanding: MRSA is a serious infection that can be difficult to treat and can spread. It is important for the client to understand the severity of MRSA.
  2. "I should wash my hands and encourage others who are around me to wash their hands."
    Understanding: Hand hygiene is critical in preventing the spread of MRSA. The client is aware of the importance of hand washing for infection control.
  3. "I will no longer be able to transmit MRSA once my surgical site is completely healed."
    No Understanding: MRSA can be a persistent infection, and healing of the surgical site does not guarantee that MRSA cannot be transmitted. Proper infection control measures must continue.
  4. "My diet makes a difference in my ability to heal."
    Understanding: Nutrition plays a role in the healing process and overall recovery. A balanced diet supports the immune system and aids in wound healing.
  5. "I should only take antibiotics until I feel better."
    No Understanding: It is crucial to complete the full course of antibiotics as prescribed to ensure the infection is fully treated and to prevent resistance

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