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 B
Explanation
Choice A rationale
Advancing from clear liquids as tolerated is important for the patient’s nutritional intake and postoperative recovery. However, it is not the most urgent task upon admission from the PACU. The nurse must first address immediate needs such as infection prevention and monitoring vital signs before considering dietary advancements. This step can be implemented once the patient’s initial postoperative stability is confirmed.
Choice B rationale
Administering cefazolin 1 gram IV every 6 hours is critical for preventing postoperative infections, especially in patients with surgical wounds. Prophylactic antibiotics are essential in reducing the risk of surgical site infections, which can lead to severe complications. Timely administration of antibiotics helps maintain therapeutic levels in the bloodstream, providing effective coverage against potential pathogens and promoting a positive postoperative outcome.
Choice C rationale
Straight catheterization if unable to void is important for managing urinary retention and preventing bladder distention. However, this intervention should be based on the patient’s condition and the amount of time since the last voiding. It is not the most urgent action upon admission from the PACU unless the patient is exhibiting signs of significant discomfort or bladder distention. Monitoring the patient’s urinary output is important but should follow the administration of prophylactic antibiotics.
Choice D rationale
Completing a blood cell count (CBC) in the morning is important for assessing the patient’s overall health and detecting any potential complications such as anemia or infection. However, it is not the most urgent action upon admission from the PACU. The nurse should prioritize tasks that address immediate postoperative needs, such as administering antibiotics and monitoring vital signs, before scheduling routine blood tests.
Correct Answer is ["A","B","C","D"]
No explanation
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