A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the clients is the nurse’s priority?
A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post meal capillary blood glucose is now 160 mg/dL
A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg
A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6
A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous
The Correct Answer is B
A. A client who has a prescription for insulin, and his premeal capillary blood glucose was 110 mg/dL, and his post-meal capillary blood glucose is now 160 mg/dL:
While changes in blood glucose levels are important to monitor, the described change is not as significant as a sudden drop in blood pressure. The blood glucose levels in this scenario are still within a reasonable range.
B. A client whose blood pressure at 0800 was 138/86 mm Hg, and at 1200 is 106/60 mm Hg:
This is the priority client. The significant drop in blood pressure raises concerns about hypovolemia or circulatory issues, which require immediate attention to prevent complications such as inadequate organ perfusion.
C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 and now reports pain as 6:
Pain management is important, but the change in pain intensity from 4 to 6, while indicating an increase, may not be as urgent as addressing a significant drop in blood pressure. Pain assessment and management can be addressed after stabilizing the client with the acute change.
D. A client whose wound drainage at 0800 was sanguineous, and now it is serosanguineous:
Changes in wound drainage color can be important for assessing the healing process, but a shift from sanguineous to serosanguineous is generally within the expected progression of wound healing. It may not require immediate intervention as compared to a significant drop in blood pressure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Prepare to administer a sedative:
Administering a sedative is not the priority in this situation. The client is experiencing shortness of breath, tachycardia, and hypoxemia, indicating a respiratory issue that needs immediate attention. Sedation can further depress the respiratory drive and exacerbate the hypoxemia.
B. Assess for indications of pulmonary embolism:
While the client's symptoms could be related to a pulmonary embolism, the priority at this moment is to address the immediate respiratory distress. Administering oxygen is crucial before further diagnostic assessments can take place. Once the client is stabilized, additional assessments can be performed to explore the cause of the symptoms.
C. Administer oxygen via face mask:
This is the correct and priority intervention. The client is hypoxic (SaO2 86%) with a low PaO2 and high respiratory rate. Administering oxygen via a face mask aims to improve oxygenation and relieve the hypoxemia associated with the respiratory distress.
D. Prepare for mechanical ventilation:
Mechanical ventilation may be considered if the client's respiratory distress is severe and not responsive to oxygen therapy. However, the immediate step is to administer oxygen via a face mask. If the client's condition does not improve with oxygen therapy, mechanical ventilation may be the next step.
Correct Answer is B
Explanation
A. An increase in the CMV rate:
Increasing the continuous mandatory volume (CMV) rate would provide more mandatory breaths, which may not address the patient's respiratory acidosis. It could potentially worsen the situation by causing respiratory alkalosis.
B. Change to SIMV (Synchronized Intermittent Mandatory Ventilation) MODE
The patient's arterial blood gas results indicate respiratory acidosis with an elevated PaCO2 (50 mmHg) and a low pH (7.30). The nurse would recommend changing to SIMV mode to allow for spontaneous breaths in addition to the set mandatory breaths. This change helps the patient to have more control over their respiratory efforts and may assist in lowering the PaCO2.
C. A decrease in the PaO2:
Decreasing the partial pressure of oxygen (PaO2) is not an appropriate response, especially when the patient is already on mechanical ventilation and has a moderate PaO2 level. The primary concern is the elevated PaCO2 and respiratory acidosis.
D. A decrease in the CMV rate:
Decreasing the CMV rate would reduce the number of mandatory breaths, potentially allowing the patient to hypoventilate further and retain more carbon dioxide. This is not the appropriate intervention for a patient with respiratory acidosis.
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