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

Correct answer: A

A.It is important to document the location of the identification tag to ensure proper identification of the body. This is crucial for legal and administrative purposes and helps prevent any potential confusion or misidentification.

B.A copy of the client's advance directivesis an important document for healthcare providers to have during the client's care but is not typically included in the post-mortem documentation. Advance directives are typically stored separately and are more relevant to the client's care while they are alive.

C. Cause of the client's death: Determining and documenting the cause of death is typically the responsibility of the attending physician or medical examiner, not the nurse.

D.The last set of the client's vital signs in (option D) may be relevant during the client's care and treatment but may not be specifically included in the post-mortem documentation. The focus of post-mortem documentation is usually on aspects such as the cause of death, time of death, interventions performed, and any significant findings related to the client's condition or autopsy.

A. I need to use iodine to disinfect cuts on my feet. B. I should soak my feet in warm water every morning. C. I will wear a clean pair of cotton socks each day. D. I can remove ingrown toenails at home as needed.

Correct Answer is C

Explanation

Explanation

C. I will wear a clean pair of cotton socks each day

Wearing a clean pair of cotton socks each day is an important aspect of foot care for individuals with diabetes. Here's why the other options are incorrect:

Using iodine to disinfect cuts on the feet in (option A) is not recommended for individuals with diabetes as it can be irritating to the skin and delay wound healing. It is best to clean cuts with mild soap and water and consult a healthcare professional for proper wound care.

Soaking feet in warm water every morning in (option B) is not recommended for individuals with diabetes. Prolonged exposure to water can increase the risk of dryness and cracking, leading to skin breakdown and infections. It is advisable to avoid prolonged soaking and to dry the feet thoroughly after washing.

Removing ingrown toenails at home in (option D) is not recommended for individuals with diabetes. Attempting to do so can result in injury and increase the risk of infection. It is important for individuals with diabetes to seek professional care for any foot-related concerns, including ingrown toenails.

In summary, the correct statement is C: "I will wear a clean pair of cotton socks each day." This demonstrates an understanding of the importance of foot hygiene and minimizing moisture to reduce the risk of fungal infections and foot complications for individuals with diabetes.

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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 completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about foot care with a client who has type 2 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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