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 A

Explanation

A. Chadwick’s sign

Chadwick's sign is a characteristic change that occurs during pregnancy, specifically in the cervix, vagina, and vulva. It is characterized by a bluish or purplish discoloration of these areas.

Chloasma in (option B) is incorrect because it is a condition characterized by the development of dark patches on the skin, commonly referred to as "mask of pregnancy." Chloasma typically affects the face, particularly the cheeks, forehead, and upper lip. It is not associated with a change in colour in the vaginal or vulvar area.

Hegar's sign in (option C) is incorrect because it is a softening of the lower uterine segment that can be felt during a pelvic examination. It is not related to the colour changes in the vaginal or vulvar area.

Ballottement in (option D) is incorrect because it is a palpation technique used during a prenatal examination to assess the position of the foetus. It involves the examiner gently pushing against the uterus and feeling a rebound or "floating" movement of the foetus. It does not involve changes in the colour of the vaginal or vulvar area.

A. Conduct change-of-shift report near the clients' rooms. B. Turn on overhead lights briefly when checking IV lines. C. Open curtains between clients in semiprivate rooms. D. Wear shoes with rubber soles.

Correct Answer is D

Explanation

Wearing shoes with rubber soles can minimize noise and provide a quieter environment for the clients. It helps reduce disruptions caused by footsteps, especially during nighttime when clients are trying to sleep.

Conducting change-of-shift report near the clients' rooms can lead to increased noise levels and disturb clients' sleep. It is best to conduct report in a designated area away from patient rooms to minimize disruptions.

Overhead lights should be avoided during nighttime or sleep hours as they are bright and can disrupt a client's sleep. Instead, nurses should use a low-intensity light or a flashlight to check IV lines or attend to other needs. This helps minimize disruptions to the client's rest.

Opening curtains between clients in semiprivate rooms can compromise privacy and contribute to increased noise levels. It is important to provide privacy for clients, especially during their rest periods.

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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

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