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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Neisseria gonorrhoeae is a sexually transmitted infection that is reportable to public health authorities due to its potential for spreading rapidly within a population and its significant public health implications. Reporting cases of Neisseria gonorrhoeae infection allows for appropriate monitoring, treatment, and control measures to be implemented to prevent further transmission and protect public health.
Sarcoptes scabiei, which causes scabies, is a contagious skin infestation but is not typically a reportable condition to the state health department.
Human papillomavirus (HPV) is a common sexually transmitted infection, but it is not generally reportable unless it is associated with certain high-risk strains and leads to specific conditions such as cervical cancer.
Impetigo contagiosa, a bacterial skin infection, is not usually a reportable condition unless there is an outbreak or unusual circumstances warranting public health intervention.
Correct Answer is D
Explanation
Using the overbed trapeze helps the client strengthen their upper body and improve mobility by allowing them to independently move and reposition themselves in bed. This promotes independence in activities of daily living and reduces reliance on nursing assistance.
Cautioning the client to avoid a prone position while in bed is important for preventing pressure ulcers and maintaining proper positioning, but it does not specifically promote independence and mobility.
Keeping a loose, absorbent dressing over the surgical site is important for wound care and infection prevention, but it does not directly promote mobility or independence. Maintaining abduction of the client's residual limb with a pillow is important to prevent contractures, but it does not directly promote mobility or independence.
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