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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

A defined area of cool, boggy skin is not indicative of a stage 2 pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss, usually appearing as a shallow open ulcer with a red-pink wound bed, without slough or bruising.

Choice B rationale:

A shallow crater involving the epidermis is characteristic of a stage 2 pressure injury. It presents as a partial-thickness skin loss with the loss of the epidermis, and the wound may be superficial and appear as an abrasion, blister, or shallow ulcer.

Choice C rationale:

The reddened area that does not blanch is more indicative of an early-stage pressure injury (Stage 1). In Stage 1, the skin remains intact, but there is non-blanch-able erythema indicating damage to the skin and underlying tissue.

Choice D rationale:

Undermining or tunneling of the skin is not specific to stage 2 pressure injuries. These features may be observed in more advanced stages of pressure injuries, such as stages 3 and 4, where there is full-thickness skin loss with damage to the subcutaneous tissue and underlying structures.

A. Fruity smelling breath. B. Painful urination. C. Hypotension. D. Lethargy.

Correct Answer is D

Explanation

Choice A rationale:
Fruity-smelling breath is associated with diabetic ketoacidosis (DKA), which is not the expected manifestation of chronic kidney disease (CKD). DKA occurs in uncontrolled diabetes and is not the priority for this client.
Choice B rationale:
Painful urination is not a typical clinical manifestation of chronic kidney disease. It is more commonly associated with urinary tract infections or other urological issues.
Choice C rationale:
Hypotension may occur in end-stage kidney disease, but it is not specific to chronic kidney disease and is not a priority in this scenario.
Choice D rationale:
Lethargy is a common clinical manifestation of chronic kidney disease due to the accumulation of waste products in the blood, leading to uremia. It is a priority as it indicates the progression of the disease and the need for close monitoring and intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing an admission assessment of a client. Which of the following findings should the nurse identify as a stage 2 pressure injury?

Correct Answer is B

Explanation

A nurse is caring for a client who has chronic kidney disease. The nurse should expect the client to have which of the following clinical manifestations?

Correct Answer is D

Explanation

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