A nurse is assessing a client's vital signs. The oxygen saturation is 85%. What intervention should the nurse perform first?
Call the provider
Place the client in the lithotomy position
Raise the head of the bed
Obtain pain medication
The Correct Answer is C
Choice A reason: Calling the provider is not the intervention that the nurse should perform first, because it is not the most urgent and relevant action. Calling the provider is a communication intervention, not a respiratory intervention. Calling the provider is an important action, but it should be done after raising the head of the bed, and with accurate and complete information.
Choice B reason: Placing the client in the lithotomy position is not the intervention that the nurse should perform first, because it is not the most urgent and relevant action. Placing the client in the lithotomy position is a positioning intervention, not a respiratory intervention. Placing the client in the lithotomy position is a specific action that is used for pelvic examinations or procedures, not for improving oxygenation.
Choice C reason: Raising the head of the bed is the intervention that the nurse should perform first, because it is the most urgent and relevant action. Raising the head of the bed is a respiratory intervention, not a communication, positioning, or analgesic intervention. Raising the head of the bed is a simple and effective action that can improve the client's breathing, oxygenation, and comfort.
Choice D reason: Obtaining pain medication is not the intervention that the nurse should perform first, because it is not the most urgent and relevant action. Obtaining pain medication is an analgesic intervention, not a respiratory intervention. Obtaining pain medication is an important action, but it should be done after raising the head of the bed, and with a medical order and a proper route.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: "Tomorrow will be better." is not a statement that demonstrates empathy, but rather one that demonstrates false reassurance or denial. False reassurance or denial is a communication barrier that dismisses or minimizes the client's feelings or concerns, and offers unrealistic or vague promises that may not be fulfilled. False reassurance or denial can make the client feel invalidated, misunderstood, or hopeless.
Choice B reason: "This must be hard news to hear. Tell me more about it." is a statement that demonstrates empathy, which is the ability to understand and share the feelings of another person. Empathy is a communication skill that acknowledges and validates the client's feelings or concerns, and invites the client to express and explore them further. Empathy can make the client feel supported, respected, and empowered.
Choice C reason: "What is your biggest fear about this diagnosis?" is not a statement that demonstrates empathy, but rather one that demonstrates probing or prying. Probing or prying is a communication barrier that asks intrusive or inappropriate questions that may make the client feel uncomfortable, defensive, or threatened. Probing or prying can make the client feel violated, judged, or pressured.
Choice D reason: "I believe you can overcome this because I've seen how strong you are." is not a statement that demonstrates empathy, but rather one that demonstrates stereotyping or labeling. Stereotyping or labeling is a communication barrier that assigns a fixed or generalized characteristic to a person or a situation, without considering the individuality or uniqueness of the person or the situation. Stereotyping or labeling can make the client feel objectified, devalued, or misunderstood.
Correct Answer is C
Explanation
Choice A reason: Purulent exudate is a thick, yellowgreen, or brown pus that indicates infection. It is not bloodtinged and does not drip from the wound.
Choice B reason: Serous exudate is a clear, thin, and watery fluid that is normal in the inflammatory stage of wound healing. It does not contain blood cells and is not red in color.
Choice C reason: Serosanguineous exudate is a pink or red fluid that contains both serum and blood. It is common in the proliferative stage of wound healing and may drip from the wound due to increased capillary permeability.
Choice D reason: Sanguineous exudate is a bright or dark red fluid that consists mostly of blood. It indicates active bleeding and is usually seen in traumatic or surgical wounds. It is not diluted with serum and is more viscous than serosanguineous exudate.
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