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 ["31"]
Explanation
Total volume to be infused: 250 mL of tube feeding.
To be infused over 8 hours.
Calculate the infusion rate in mL per hour.
Infusion rate (mL/hour) = Total volume (mL) / Total infusion time (hours)
= 250 mL / 8 hours
= 31.25
Round to the nearest whole number: 31.
Correct Answer is A
Explanation
A. A liquid nutritional supplement that contains protein: A full liquid nutritional supplement with added protein is best because protein is critical for skin integrity and tissue repair. Supplements also provide balanced calories, vitamins, and minerals necessary to support overall skin health and prevent breakdown.
B. Beef broth, or chicken broth: While broth provides fluids and some electrolytes, it is very low in calories and protein, making it insufficient alone for preventing impaired skin integrity in a client with reduced oral intake.
C. Fortified lowfat milk: Milk offers some protein and nutrients, but a specialized nutritional supplement is more calorie-dense and protein-rich, providing a more comprehensive solution for a client at risk for skin breakdown.
D. Apple or grapefruit juice: Fruit juices offer hydration and some vitamins but lack significant protein and calories. They are inadequate for maintaining skin integrity, especially when protein intake is a primary concern.
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