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 C
Explanation
Choice A rationale:
This statement indicates the client's fear and concern about the colostomy's odor, showing a lack of adaptation to the situation.
Choice B rationale:
Comparing the stoma to a strawberry with a hole in it might suggest the client is not fully accepting or understanding the colostomy, indicating a lack of adaptation.
Choice C rationale:
This statement suggests that the client has delegated the task of emptying the colostomy bag to their partner, which indicates a level of acceptance and adaptation to the new situation.
The client trusts their partner with this intimate task, demonstrating a positive sign of adaptation.
Choice D rationale:
Eliminating many foods from the diet suggests difficulty in adjusting to the dietary changes required for managing a colostomy, indicating a lack of full adaptation.
Correct Answer is C
Explanation
Choice A rationale:
Taking sitz baths can provide comfort but will not directly address the transmission of herpes simplex virus type 2 (HSV-2). It is essential to avoid sexual activity during outbreaks to prevent spreading the infection to a partner.
Choice B rationale:
Cleansing lesions with 1/2 strength peroxide may irritate the affected area and delay healing. The recommended approach is to use gentle soap and water to clean the lesions.
Choice C rationale:
"I will avoid sexual activity until my lesions are healed.”. This statement indicates an understanding of the teaching because HSV-2 is highly contagious during active outbreaks. Avoiding sexual activity during this time is essential to prevent transmitting the virus to a partner.
Choice D rationale:
"I am not contagious once I begin antiviral medication.”. This statement is incorrect as antiviral medications can help manage outbreaks but do not eliminate the risk of transmission entirely. The virus remains contagious until lesions are completely healed.
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