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.
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Related Questions
Correct Answer is A
Explanation
A. Hoarseness in the voice following a thyroidectomy can be a sign of vocal cord damage or laryngeal nerve injury, which are potentially serious complications. The appropriate action is to notify the unit charge nurse to escalate the finding for further assessment by a physician or advanced practice provider.
B. Administering humidified oxygen does not specifically address the issue of hoarseness. While humidified oxygen might be beneficial for general respiratory comfort, it is not a targeted intervention for potential vocal cord damage.
C. Ensuring that the drainage device is compressed is important for managing surgical wounds but does not address or diagnose vocal cord issues. Hoarseness after thyroid surgery is more indicative of a potential complication rather than a drainage issue.
D. Obtaining ice chips does not address the underlying cause of the hoarseness and may not provide significant relief. The priority is to identify potential complications rather than offering symptomatic relief.
Correct Answer is A
Explanation
A. Diaper changes help assess the baby’s urinary output and general hydration status. If the newborn is producing urine, it suggests proper kidney function and adequate fluid intake, which are essential considerations before transferring the baby to the nursery.
B. While this promotes bonding and allows the mother to assess her baby visually, it does not directly address health indicators such as feeding or elimination, which are critical for ensuring the newborn’s well-being.
C. Noting if the baby is sleeping is a routine observation but does not address the importance of maternal bonding.
D. Whether the family has seen the baby is less critical than ensuring the mother has had early bonding opportunities.
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