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 B
Explanation
This statement shows that the mother understands the importance of having matching identification bands for herself and her baby. Matching identification bands help ensure proper identification and prevent any mix-ups or unauthorized individuals from gaining access to the baby. It is a security measure commonly implemented in healthcare facilities to protect the well-being and safety of both the mother and the newborn.
Correct Answer is ["C"]
Explanation
A: The tubing should not be coiled on the bed, especially not above the collection bag, as this can interfere with the drainage of urine and increase the risk of infection.
B: The drainage bag should always be kept below the level of the bladder during ambulation to prevent backflow and reduce the risk of infection.
C: Securing the catheter tubing to the lower abdomen (for male clients) or thigh (for female clients) helps to reduce the risk of catheter displacement and trauma. Proper securing also prevents unnecessary tension on the tubing, which can cause urethral irritation.
D:A sterile specimen should be collected from the sampling port of the catheter tubing, not directly from the drainage bag, which could lead to contamination.
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