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 D

Explanation

A.Having a health care proxy does not mean that the individual relinquishes their right to make their own decisions. A health care proxy is designated to make decisions on behalf of the individual when they are unable to do so, but the individual retains the right to make decisions if they are capable.

B.Having a health care proxy does not eliminate the need for a living will. A living will outline the individual's specific wishes regarding medical treatments and end-of-life care, while a health care proxy designates a person to make decisions on their behalf. Both documents serve different purposes and can work together to ensure the individual's wishes are respected.

C.A health care proxy designee is typically empowered to make medical decisions on your behalf, including signing consent forms if necessary. This is one of the primary roles of a health care proxy – to act in your best interests when you are unable to make decisions yourself, including signing forms for procedures or treatments.

D.The individual has the choice to name any person as their health care proxy designee, regardless of their relationship. It is important to choose someone who understands the individual's wishes and can make decisions in their best interest. The decision of whom to name as the health care proxy designee is personal and should be based on trust and understanding.

A. Constipation B. Blurred vision C. Hypertension D. Muscle cramps

Correct Answer is D

Explanation

Explanation

D. Muscle cramps

Hyponatremia is a condition characterized by low levels of sodium in the blood. Sodium plays a crucial role in maintaining fluid balance and nerve and muscle function. When sodium levels are low, it can lead to imbalances in fluid levels and cause muscle cramps and weakness.

Constipation in (option A) is incorrect because it is more commonly associated with other conditions such as dehydration or electrolyte imbalances like hypercalcemia.

Blurred vision in (option B) is not a typical finding in hyponatremia. Visual disturbances may occur in severe cases, but they are not a consistent symptom.

Hypertension (high blood pressure) in (option C) is not typically associated with hyponatremia. In fact, hyponatremia can sometimes lead to low blood pressure (hypotension) due to the fluid imbalances it causes.

Therefore, the nurse should expect muscle cramps (option D) as a finding in a client with hyponatremia due to the disruption of fluid balance and its impact on muscle function.

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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

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