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 A
Explanation
Choice A reason: Psoriasis is a skin abnormality that causes patches of thick, red skin with silvery scales, usually on the elbows, knees, scalp, lower back, or genitals. Psoriasis is a chronic, inflammatory, autoimmune condition that affects the life cycle of skin cells, causing them to build up rapidly on the surface of the skin. Psoriasis can cause itching, burning, pain, or bleeding.
Choice B reason: Rosacea is a skin abnormality that causes redness, flushing, swelling, or pimples, usually on the face, especially the cheeks, nose, chin, or forehead. Rosacea is a chronic, inflammatory, vascular condition that affects the blood vessels and sebaceous glands of the skin. Rosacea can cause sensitivity, stinging, or dryness.
Choice C reason: Scabies is a skin abnormality that causes small, red bumps, blisters, or burrows, usually on the hands, wrists, feet, ankles, or genitals. Scabies is a contagious, parasitic infection that is caused by tiny mites that burrow into the skin and lay eggs. Scabies can cause intense itching, especially at night.
Choice D reason: Stasis dermatitis is a skin abnormality that causes swelling, redness, scaling, or ulcers, usually on the lower legs or ankles. Stasis dermatitis is a chronic, inflammatory condition that results from poor blood circulation in the veins of the legs, causing fluid to leak into the surrounding tissues. Stasis dermatitis can cause pain, itching, or infection.
Correct Answer is D
Explanation
Choice A reason: This is an unrealistic and unattainable goal for a client with rheumatoid arthritis. Rheumatoid arthritis is a chronic and progressive inflammatory disease that causes joint pain, stiffness, swelling, and deformity. It is not possible to eliminate pain completely with this condition. The nurse should help the client set realistic and individualized goals for pain management.
Choice B reason: This is a vague and subjective goal for pain control. Pain is a personal and multidimensional experience that varies from person to person. The nurse should use a valid and reliable pain assessment tool, such as the numeric rating scale, to measure the client's pain intensity and quality. The nurse should also ask the client about their acceptable level of pain and how it affects their daily activities and quality of life.
Choice C reason: This is a good goal for general health and wellness, but it is not specific to pain control. Eating healthy meals and staying hydrated can help the client maintain their nutritional status and hydration, which are important for overall health. However, they do not directly address the pain caused by rheumatoid arthritis. The nurse should also consider other factors that can influence pain, such as stress, mood, sleep, and coping strategies.
Choice D reason: This is the best goal for pain control in a client with rheumatoid arthritis. It is realistic, measurable, and individualized. It acknowledges that some pain is inevitable with this condition, but it aims to reduce it to a tolerable level that allows the client to function and enjoy life. It also uses a numeric rating scale to quantify the pain and monitor the effectiveness of interventions.
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