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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Regular physical exercise has been shown to promote better sleep. Engaging in daily exercise can help regulate the sleep-wake cycle, promote relaxation, reduce anxiety and stress, and increase overall sleep quality. It is important to note that exercise should ideally be done earlier in the day, at least a few hours before bedtime, as exercising too close to bedtime may actually have a stimulating effect and make it harder to fall asleep.
The other options listed are not the most appropriate recommendations for addressing difficulty in falling asleep:
- "Sleep longer hours on the weekend." This suggestion may disrupt the client's sleep routine and can lead to inconsistent sleep patterns throughout the week, potentially making it more challenging to fall asleep on subsequent nights.
- "Keep the television volume low while you are trying to fall asleep." It is generally recommended to create a sleep-friendly environment, which includes reducing external stimuli like noise, light, and electronic devices in the bedroom. However, watching television right before bedtime can interfere with sleep as the bright light and stimulating content can keep the mind awake.
- "Remain in bed until you fall asleep." This recommendation may contribute to increased frustration and anxiety if the client is unable to fall asleep quickly. It is generally advised to practice good sleep hygiene, which includes getting out of bed if unable to fall asleep after a reasonable amount of time and engaging in a relaxing activity until feeling sleepy again.
Correct Answer is C
Explanation
Delirium is a state of acute confusion and cognitive impairment that can cause disorientation and difficulty with time perception. Reminding the client of the day and time frequently helps provide orientation and reduce confusion. It can help ground the client in reality and improve their understanding of their current circumstances.
Avoiding discussing the client's fears can hinder their ability to express and address their concerns. It is important to provide a safe and supportive environment where the client can communicate their fears and feelings.
Offering the client several choices at mealtimes might be overwhelming and confusing for someone experiencing delirium. It is generally better to provide structure and simplicity in their meal options, reducing decision-making demands.
Alternating daily caregivers can disrupt continuity of care and increase the client's confusion. Consistency in the caregiving team can help establish a therapeutic relationship and familiarity, which can aid in managing delirium.
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