A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations. Which of the following is the priority action by the nurse?

Establish a patent airway for the client

Administer oxygen to the client

Place a pulse oximeter on the client's finger

Check the client's pulse rate

Answer and Explanation

The Correct Answer is A

A respiratory rate of 8 breaths per minute with shallow respirations and cyanosis indicates significant respiratory distress and inadequate oxygenation. The client's airway needs to be assessed and cleared to ensure a proper flow of air into the lungs. This can involve positioning the client appropriately, providing manual or mechanical assistance with ventilation, or using other airway management techniques as necessary.

While administering oxygen to the client and placing a pulse oximeter on the client's finger are important interventions to improve oxygenation and monitor oxygen saturation, they should not delay the immediate priority of establishing a patent airway.

Checking the client's pulse rate is also important and should be done in a timely manner, but it should not take precedence over ensuring a clear and open airway for the client.

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Correct Answer is C

Explanation

"My baby will receive the rotavirus immunization orally." - This statement is correct. The rotavirus vaccine is administered orally, typically as drops or as an oral suspension. It is important for the guardian to follow the specific instructions provided by the healthcare provider for the administration of the rotavirus vaccine.

"I should not feed my baby anything for 2 hours prior to an immunization." - This statement is incorrect. It is not necessary to withhold feeding prior to immunizations. In fact, it is generally recommended to feed the baby before the immunization to help provide comfort during the procedure.

"My baby will receive three doses of the meningococcal immunization before kindergarten." This statement is incorrect. The number of doses and the schedule for each immunization may vary. The guardian should consult with the healthcare provider or refer to the immunization schedule for the specific recommendations regarding the meningococcal immunization.

"I should expect my baby to have a high fever for 24 hours after an immunization." - This statement is not entirely accurate. While it is common for infants to experience mild side effects such as a low-grade fever after immunizations, a high fever is less common. The guardian should be aware of the potential side effects and contact the healthcare provider if they have concerns about their baby's reaction to the immunization.

A. Provide the client with written information about advance directives B. Instruct the client that an advance directive is a legal document and must be honored by care providers C. Initiate a power of attorney for health care document D. Communicate advance directives status via the medical record and shift report E. Document that the provider discussed-do-not-resuscitate status with the client F. Inform the client that an advance directive discontinues further care

Correct Answer is ["A","B","C","D"]

Explanation

Provide the client with written information about advance directives: It is important for the nurse to educate the client about advance directives, their purpose, and how they can make informed decisions about their healthcare.

Instruct the client that an advance directive is a legal document and must be honored by care providers: The nurse should explain to the client that an advance directive is a legally binding document that guides healthcare decisions, and it must be respected and followed by healthcare providers.

Communicate advance directives status via the medical record and shift report: The nurse should ensure that the client's advance directives status is accurately documented in the medical record and communicated to other members of the healthcare team during shift handoffs. This helps ensure that the client's wishes are known and respected by all involved in their care.

Initiate a power of attorney for health care document: The nurse can assist the client in initiating a power of attorney for healthcare document if the client wishes to appoint someone as their healthcare proxy or agent. This document designates someone to make medical decisions on behalf of the client if they become unable to do so.

The other options listed are not appropriate or accurate in relation to the responsibilities of the nurse regarding advance directives:

Document that the provider discussed-do-not-resuscitate status with the client: While discussing do-not-resuscitate (DNR) status may be part of the advance care planning process, it is not directly related to advance directives as a whole.

Inform the client that an advance directive discontinues further care: This statement is incorrect and misleading. An advance directive does not automatically discontinue care but rather guides the provision of care according to the client's wishes.

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A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations. Which of the following is the priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with the guardian of a 2-month-old infant about immunizations. Which of the following statements by a guardian indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client. Laboratory Results 1100: Abdominal ultrasound: mass present in small intestine proximal to ileocecal valve. Size of mass is 6 cm x 7 cm (2.4 in x 2.8 in). Select the 4 responsibilities the nurse has in relation to the client's advance directives.

Correct Answer is ["A","B","C","D"]

Explanation

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