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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?

A.

Establish a patent airway for the client

B.

Administer oxygen to the client

C.

Place a pulse oximeter on the client's finger

D.

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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Related Questions

Correct Answer is D

Explanation

Hair loss is a common side effect of chemotherapy, and it can have a significant impact on the client's self-esteem and body image. The nurse should respond with empathy and provide supportive information and resources to help the client cope with hair loss.

Offering head-covering options such as wigs, scarves, or hats can help the client feel more comfortable and confident during the hair loss process.

The other responses are less appropriate:

  1. "I can't imagine how difficult it would be to lose my hair." While expressing empathy is important, it is crucial to focus on the client's needs and experiences rather than the nurse's own feelings. This response may unintentionally minimize the client's concerns.
  2. "I wouldn't worry about this right now. Let's focus on your chemotherapy." Dismissing or minimizing the client's concerns about hair loss can be invalidating and may not address the emotional impact it can have on the client. It is important to provide information and support regarding hair loss management as part of comprehensive care.
  3. "Let's discuss this when we have more time." This response delays addressing the client's concerns and may leave the client feeling unheard or dismissed. The nurse should make an effort to provide support and information in a timely manner to address the client's needs.

Correct Answer is C

Explanation

Fontanels are soft spots on an infant's skull where the bones have not yet fused together. The anterior fontanel, located at the front of the head, typically closes between 12 to 18 months of age. The posterior fontanel, located at the back of the head, usually closes by 2 to 3 months of age.

The other findings mentioned are typical developmental milestones for a 4-month-old infant:

  1. Rolling from back to abdomen: By 4 months of age, it is expected that infants can roll from their back to their abdomen. This is a normal developmental milestone.
  2. Moves objects to mouth: At 4 months, infants begin to develop hand-eye coordination and the ability to reach for objects. Bringing objects to the mouth is a typical behavior at this age as infants explore their environment.

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