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 A
Explanation
Explanation:
Methylenedioxyphenol-methamphetamine (MDMA), also known as ecstasy or Molly, is a psychoactive substance that can produce hallucinations as one of its effects. Hallucinations involve perceiving things that are not present in reality, such as seeing, hearing, or feeling things that do not actually exist.
Muscle weakness (choice B) is not a common finding associated with MDMA use. In fact, MDMA typically produces an increase in energy and heightened physical sensations rather than muscle weakness.
Hypothermia (choice C) can occur as a result of MDMA use. MDMA can interfere with the body's ability to regulate temperature, leading to an increase in body temperature. This is commonly known as "drug-induced hyperthermia" rather than hypothermia.
Somnolence (choice D), which refers to excessive sleepiness or drowsiness, is not typically associated with MDMA use. MDMA is a stimulant drug that can produce increased wakefulness and alertness.
Correct Answer is A
Explanation
Observing the client during and after meals is crucial for monitoring their eating behaviors, identifying any signs of bingeing or purging, and assessing their overall progress in managing their eating disorder. By closely observing the client, the nurse can provide immediate support and intervention if necessary and help prevent or address any potentially harmful behaviors. Instructing the client about effective coping strategies is valuable in helping them develop healthier ways to manage stress and emotions. However, this instruction can be more effective once the nurse has observed the client's behaviors and identified specific areas where coping strategies are needed.
Suggesting that the client assist with meal planning can be a helpful step in empowering them to take ownership of their eating habits and make healthier choices. However, before involving the client in meal planning, it is important to first assess their current eating behaviors and address any immediate concerns or risks.
Referring the client to a support group for individuals with eating disorders is a beneficial step in providing ongoing support and community. However, this referral can be made once the nurse has established a baseline understanding of the client's behaviors and needs.
Observing the client during and after meals is crucial for monitoring their eating behaviors, identifying any signs of bingeing or purging, and assessing their overall progress in managing their eating disorder. By closely observing the client, the nurse can provide immediate support and intervention if necessary and help prevent or address any potentially harmful behaviors. Instructing the client about effective coping strategies is valuable in helping them develop healthier ways to manage stress and emotions. However, this instruction can be more effective once the nurse has observed the client's behaviors and identified specific areas where coping strategies are needed.
Suggesting that the client assist with meal planning can be a helpful step in empowering them to take ownership of their eating habits and make healthier choices. However, before involving the client in meal planning, it is important to first assess their current eating behaviors and address any immediate concerns or risks.
Referring the client to a support group for individuals with eating disorders is a beneficial step in providing ongoing support and community. However, this referral can be made once the nurse has established a baseline understanding of the client's behaviors and needs.
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