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. Place the suppository high in the rectum: Inserting the suppository high in the rectum ensures that it is positioned beyond the anal sphincter, where it can be effectively absorbed. Proper placement maximizes the medication's effect and prevents expulsion, which is critical for achieving pain relief and antispasmodic benefits after prostate surgery.
B. Allow the suppository to soften before insertion: Allowing the suppository to soften may make it difficult to insert and can result in incomplete delivery of the medication. A firm suppository is easier to insert properly and ensures accurate medication placement and effectiveness.
C. Freeze the suppository prior to insertion: Freezing the suppository is not recommended because it can make it too hard and sharp, potentially causing trauma to delicate rectal tissues, especially in a postoperative client who may already have increased sensitivity and healing tissues.
D. Avoid use of a lubricant with insertion of the suppository: Using a water-soluble lubricant is important during suppository insertion to minimize mucosal trauma and facilitate smoother placement. Avoiding lubrication can cause unnecessary discomfort and increase the risk of rectal injury.
Correct Answer is D
Explanation
A. Breast pads wet with breast milk from a postpartum client with mastitis: Although mastitis involves infection, breast milk is not classified as a biohazard unless visibly contaminated with blood. Breast pads wet only with milk would typically be discarded in regular waste, not biohazard containers.
B. Straight urinary catheter tray used to collect a urine specimen for culture: The tray may have biological material but is not heavily saturated with blood or other highly infectious fluids. Urine alone, unless grossly bloody, does not typically require disposal in a biohazard container.
C. Urine soiled disposable bed pads for a client with hepatitis C: Even though the client has hepatitis C, urine is generally not considered a high-risk fluid for transmission of bloodborne pathogens unless visibly contaminated with blood. These pads would be disposed of in regular medical waste.
D. Postoperative dressing that is saturated with bright red blood: A dressing heavily saturated with blood must be placed in a biohazard container because blood is classified as a potentially infectious material. Proper disposal prevents exposure to bloodborne pathogens and meets infection control standards.
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