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 B

Explanation

B. Make a schedule for daily task.

Creating a schedule of daily tasks can provide structure and routine for individuals with Alzheimer's disease. This helps reduce confusion and frustration by providing a sense of familiarity and predictability. The schedule should be displayed in a visible location and include activities such as meals, personal care, medication administration, and any recreational or therapeutic activities. Following the schedule can help the client feel more oriented and decrease their frustration levels.

Limiting the use of familiar objects in (option A) should not be included because it may further increase frustration and disorientation. Familiar objects can provide comfort and a sense of security for individuals with Alzheimer's disease.

Asking questions that require more than one answer in (option C) should not be included because it can be overwhelming and confusing for someone with Alzheimer's disease. It is best to ask simple, straightforward questions to facilitate communication and comprehension.

Having several family members visit daily in (option D) should not be included because it may cause agitation and overstimulation for the client. It is important to maintain a calm and predictable environment, limiting the number of visitors and ensuring they are familiar to the client.
Therefore, the most appropriate intervention for the nurse to include is making a schedule of daily tasks (option B).

A. Chlorhexidine B. Isopropyl alcohol C. Bleach D. Hydrogen peroxide

Correct Answer is C

Explanation

Explanation:

Bleach is an effective disinfectant for blood spills and is recommended by healthcare guidelines for its ability to kill a broad range of microorganisms, including bloodborne pathogens such as human immunodeficiency virus (HIV). To prepare a bleach solution, the nurse can mix 1-part bleach with 10 parts water. This diluted bleach solution can be used to clean and disinfect the overbed table surfaces that have been contaminated with blood.

A- Chlorhexidine is an antiseptic commonly used for skin preparation before invasive procedures, but it is not the ideal choice for disinfecting surfaces or objects after a blood spill.

B- Isopropyl alcohol is effective for disinfecting small surfaces, but it may not be as effective as bleach for blood spills, particularly in the context of bloodborne pathogens like HIV.

D- Hydrogen peroxide can be used as a disinfectant, but it may not be as effective as bleach in eliminating bloodborne pathogens from surfaces.

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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?

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