A nurse is caring for a client who had moderate sedation during a procedure. The client's airway is obstructing, and they have an oxygen saturation of 90%. Which of the following interventions is the first action the nurse should take?
Prepare an endotracheal tube for intubation.
Insert a plastic oral airway.
Provide oxygen using a manual resuscitation bag.
Perform a head-tilt with chin-lift.
The Correct Answer is C
Choice A rationale:
Preparing an endotracheal tube for intubation is not the first action the nurse should take in this situation. Intubation is an invasive procedure and should be reserved for cases where other, less invasive methods of airway management have failed.
Choice B rationale:
Inserting a plastic oral airway may help maintain the airway in some situations, but it is not the first action to take when the client's airway is obstructing and their oxygen saturation is low.
Choice C rationale:
Providing oxygen using a manual resuscitation bag (bag-valve-mask device) is the correct first action. This allows the nurse to manually assist the client's breathing and deliver oxygen more effectively than just providing supplemental oxygen through a nasal cannula or face mask.
Choice D rationale:
Performing a head tilt with a chin-lift is a basic airway maneuver, but it may not be sufficient in this situation, especially if the airway is completely obstructed. Providing oxygen with a manual resuscitation bag takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Placing the client on droplet precautions is appropriate for bacterial meningitis, as it is spread through respiratory droplets. This measure helps prevent the spread of infection to others.
Choice B rationale:
The nurse should clarify the prescription to perform a cranial nerve assessment every 2 hours. While cranial nerve assessment is crucial in monitoring neurological status, performing it every 2 hours is excessive and not supported by evidence-based practice. Frequent assessments can be uncomfortable for the client and may not provide additional meaningful information within such a short interval.
Choice C rationale:
Assisting the client out of bed three times per day is essential for promoting mobility and preventing complications such as pressure ulcers and muscle weakness. This prescription is appropriate and does not require clarification.
Choice D rationale:
Assessing the client's weight daily is essential in monitoring fluid balance and nutritional status. There is no need to clarify this prescription, as it is a standard practice in caring for clients with bacterial meningitis.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should maintain the affected leg elevated on several pillows to reduce swelling and promote venous return. Elevating the leg helps minimize edema, which can be beneficial for the healing process and overall comfort of the client.
Choice B rationale:
Instructing the client to wiggle the toes once every 4 hours is not necessary and may cause discomfort to the fractured tibia. Toe wiggling does not provide any significant benefit in this context and could potentially disrupt the healing process.
Choice C rationale:
Using a hair dryer to promote drying of the cast is not recommended. Applying heat to the fiberglass cast may alter its integrity and lead to uneven drying, potentially weakening the cast's support.
Choice D rationale:
Applying heat to the client's cast for pain relief is not advisable. Heat may also weaken the cast material and is unlikely to provide effective pain relief for a fractured tibia. Instead, the nurse should follow the prescribed pain management plan and use appropriate pain medications as ordered by the healthcare provider.
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.