While turning and positioning a bedfast client, the practical (PN) observes that the client is dyspneic. Which action should the PN take first?
Measure blood pressure.
Observe pressure areas.
Notify the charge nurse.
Apply a pulse oximeter.
The Correct Answer is D
A. Measure blood pressure: While assessing blood pressure provides useful data about cardiovascular status, it does not give immediate information about the client’s oxygenation level. The priority in dyspnea is to evaluate respiratory function before addressing circulatory parameters.
B. Observe pressure areas: Inspecting pressure areas is important for skin integrity in a bedfast client but is not an immediate concern when the client shows signs of respiratory distress. The focus should first be on assessing oxygen saturation and airway status.
C. Notify the charge nurse: Communication with the charge nurse is necessary, but only after the PN has obtained essential assessment data. Reporting findings such as oxygen saturation helps guide urgent interventions and escalation of care.
D. Apply a pulse oximeter: Applying a pulse oximeter is the first action because it provides rapid, objective information about the client’s oxygenation status. This allows the PN to determine the severity of hypoxia and respond promptly with appropriate interventions or reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Observe suture line for separation and hematoma formation: The first priority is assessing the episiotomy site for complications such as suture separation, bleeding, or hematoma, which could indicate a need for urgent intervention. Early identification of these issues is essential to prevent infection or further tissue damage.
B. Apply an ice pack for 20 minutes to the episiotomy: Ice can help reduce pain and swelling, but it should be applied after assessing the site. Applying ice before evaluation may mask signs of complications or delay recognition of serious issues.
C. Initiate daily warm sitz baths during onset of pain: Sitz baths are effective for pain relief and promoting healing but are a supportive intervention. They are implemented after the PN ensures there are no acute complications requiring immediate attention.
D. Check medication administration record for last PRN analgesic: Reviewing the last dose of analgesic is important for managing pain, but it is secondary to assessing the site for complications. Pain may be a symptom of a serious problem that needs prompt evaluation.
Correct Answer is A
Explanation
A. "I realize that life must go on, but sometimes I wonder why.": This indicates ongoing grief and possible depressive symptoms two years after the spouse’s death. Persistent feelings of emptiness or questioning life’s purpose beyond the normal grieving period suggest unresolved grief that may benefit from professional bereavement counseling.
B. “I depend on children who fortunately live close-by.": Relying on family for support is a normal and healthy coping mechanism in older adults. This statement reflects adaptation and use of social resources rather than signs of complicated grief or depression.
C. “I hate that my health does not allow me to do what I used to do.": Expressing frustration about physical limitations is common in aging adults and not necessarily linked to bereavement. It represents normal adjustment to aging and chronic conditions not unresolved grief.
D. "Sometimes I have trouble remembering simple things.": Occasional forgetfulness may reflect normal age-related memory changes, fatigue, or mild cognitive decline, but it is not directly related to grief.
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