A nurse is caring for a 59-year-old male client in the intermediate care unit.
Oxygen saturation of 56%
Crackles heard in the right lung
pH of 7.21
Tracheal deviation to the right
Correct Answer : A,D
Choice A rationale: Oxygen saturation of 56% is critically low and indicates severe hypoxemia, which requires immediate intervention to improve oxygenation and prevent life-threatening complications.
Choice D rationale: Tracheal deviation to the right suggests a possible tension pneumothorax, which is a medical emergency. It requires immediate attention to relieve the pressure on the affected lung and restore normal breathing.
Choice B rationale: Crackles heard in the right lung indicate fluid or atelectasis but are not immediately life-threatening compared to the other findings.
Choice C rationale: A pH of 7.21 indicates acidemia and respiratory acidosis but is a secondary concern compared to the immediate need to address the client's hypoxemia and potential tension pneumothorax.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While asking the client's family to return may provide additional support, it is not a viable long-term solution as family members may have other responsibilities and commitments. It also places undue pressure on the family.
Choice B rationale
Hiring a private nurse could be a solution, but it may not be financially feasible for all clients. It also does not address the need for a comprehensive plan for both the client and her husband.
Choice C rationale
Social services can assist in arranging respite care for the client's husband, ensuring he receives the necessary care while the client recovers. Respite care is a practical solution for temporary relief for caregivers.
Choice D rationale
A case management evaluation can help assess the client's home environment and identify any potential needs or risks. However, it does not directly address the immediate concern of providing care for the husband.
Correct Answer is ["A","C","D"]
Explanation
The correct answers are Choices A, C, and D.
Choice A rationale: Encouraging the client to increase physical activity and engage with peers is appropriate as it helps prevent deconditioning, improves cardiovascular health, and promotes mental well-being. Physical activity can also improve muscle strength, mobility, and overall quality of life.
Choice B rationale: Suggesting the client remain in bed to avoid unnecessary exertion is incorrect. Prolonged bed rest can lead to muscle atrophy, pressure injuries, and decreased cardiovascular function. The client should be encouraged to mobilize as tolerated to maintain functional abilities.
Choice C rationale: Teaching the caregiver how to monitor for signs of infection in pressure injuries is crucial because the client has stage II pressure injuries that need careful monitoring and management to prevent complications such as infection. Education on signs of infection, proper wound care, and prevention strategies is essential.
Choice D rationale: Assisting the client in using the restroom to avoid incontinence is appropriate as it respects the client's preference for toileting, reduces the risk of skin breakdown, and promotes dignity. Helping the client maintain continence and proper hygiene is important for comfort and overall health.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.