While turning and positioning a bedfast client, the practical nurse (PN) observes that the client is dyspneic. Which action should the PN take first?
Notify the charge nurse.
Apply a pulse oximeter.
Observe pressure areas.
Measure blood pressure.
The Correct Answer is B
A. Notify the charge nurse: Although informing the charge nurse is important when a client’s status changes, it should be done after gathering objective data. Immediate assessment is critical to determine the extent of dyspnea and guide further interventions, rather than escalating prematurely without vital information.
B. Apply a pulse oximeter: Applying a pulse oximeter is the first action because it quickly assesses oxygen saturation and provides objective data regarding respiratory compromise. This measurement is essential to prioritize and tailor further interventions, ensuring timely management of potentially life-threatening hypoxia.
C. Observe pressure areas: Monitoring pressure areas is important for preventing pressure injuries in bedfast clients, but it is not the priority when a client is experiencing respiratory distress. Dyspnea requires immediate evaluation of oxygenation status rather than a skin integrity assessment.
D. Measure blood pressure: Blood pressure assessment provides information about cardiovascular status but does not immediately evaluate oxygenation. While important in overall evaluation, it is not the first step when addressing acute dyspnea, where oxygen saturation takes precedence to guide urgent care decisions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Visitors should only wash hands with soap and water: Handwashing with soap and water is essential because alcohol-based sanitizers are ineffective against Clostridium difficile spores. Physical friction from washing removes spores and significantly reduces the risk of transmission.
B. Standard precautions apply to clients with active diarrhea: Clients with C. difficile require contact precautions, not just standard precautions, due to the high risk of environmental contamination and spore transmission through direct and indirect contact.
C. Clostridium difficile spores do not live long on surfaces outside of the host: C. difficile spores are very hardy and can survive on surfaces for long periods, sometimes weeks or months, making environmental cleaning and personal hygiene critical.
D. Only immunosuppressed family members should take precautions: All visitors and healthcare workers must use precautions, not just immunosuppressed individuals, because C. difficile is highly contagious and can infect healthy individuals through spore ingestion.
Correct Answer is ["B","F","G","H"]
Explanation
Vital signs are to be taken every 4 hours, as per the physician's orders. The correct times based on the 4-hour interval are:
H. 0800 (Initial time)
B. 1200 (4 hours after 0800)
F. 1600 (4 hours after 1200)
G. 2000 (4 hours after 1600)
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.