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","C"]

Explanation

Varicella zoster is highly contagious, and airborne precautions should be implemented. Assigning the client to a negative pressure airflow room helps prevent the spread of the virus to others by containing and filtering the air within the room.

In addition to airborne precautions, contact precautions should also be implemented. This includes using gloves and gowns when providing care to the client to minimize direct contact with infectious materials.

The other options listed are not appropriate interventions for a client with varicella zoster: While it is important to minimize close contact with an infectious client, varicella zoster is primarily transmitted through airborne droplets. Visitors should follow the appropriate precautions, such as wearing masks and adhering to hand hygiene, rather than just maintaining a certain distance.

Aspirin should not be given to clients with varicella zoster, especially children, due to the risk of developing Reye's syndrome. Reye's syndrome is a rare but serious condition that can cause swelling in the liver and brain. Acetaminophen (paracetamol) is typically recommended for managing fever in clients with varicella zoster.

A. Fidelity involves keeping promises made to clients. B. Fidelity involves making sure clients are able to make their own health care decisions. C. Fidelity involves ensuring that we do no harm to the client. D. Fidelity involves treating every client with the same level of respect.

Correct Answer is A

Explanation

A. Fidelity involves keeping promises made to clients

Fidelity is an ethical principle that pertains to the nurse's duty to be faithful, loyal, and keep promises made to clients. It involves acting in a trustworthy and reliable manner, maintaining commitments, and upholding the client's rights and autonomy.

Option B is incorrect because it refers to autonomy, which is another ethical principle that involves respecting the client's right to make their own health care decisions.

Option C is incorrect because it refers to nonmaleficence, which is the principle of ensuring that we do no harm to the client and avoiding actions that may cause harm or have a negative impact on the client's well-being.

Option D is incorrect because it refers to justice, which involves treating every client with fairness, equality, and respect, but it does not specifically address the concept of fidelity.

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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

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

Correct Answer is ["A","C"]

Explanation

A nurse is reviewing information about ethical client care with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of fidelity?

Correct Answer is A

Explanation

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