A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first?
A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89%
A client who has multiple sclerosis and reports ataxia and vertigo
A client who has left-sided paralysis and slurred speech from a prior stroke
A client who has thrombocytopenia and reports a nosebleed
The Correct Answer is A
Choice A Reason:
A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% is correct. The nurse should attend to the client with chronic obstructive pulmonary disease and an oxygen saturation of 89% first. Oxygen saturation levels below 90% indicate significant hypoxemia and potential respiratory distress. The client with COPD is at risk for further worsening of their condition due to inadequate oxygenation. Therefore, addressing this client's low oxygen saturation is a priority to ensure their respiratory status is stabilized.
Choice B Reason:
A client who has multiple sclerosis and reports ataxia and vertigo is incorrect. While these symptoms need assessment and care, they are not indicative of an immediate life-threatening situation.
Choice C Reason:
A client who has left-sided paralysis and slurred speech from a prior stroke is incorrect., While this client requires ongoing care, the immediate concern is lower in priority compared to addressing severe hypoxemia.
Choice D Reason:
A client who has thrombocytopenia and reports a nosebleed is incorrect. Although a nosebleed can be concerning due to thrombocytopenia, it is not as immediately critical as addressing severe hypoxemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Complete AV block with rates slower than 40/min Complete atrioventricular (AV) block, especially with rates slower than 40 beats per minute (bradycardia), is an indication for the placement of a permanent pacemaker. Complete AV block means there is a complete block in the electrical conduction between the atria and ventricles, resulting in a significant slowing or absence of impulses reaching the ventricles. This can lead to dangerously low heart rates and inadequate cardiac output.
Choice B reason:
Vasovagal bradycardia without syncope - Vasovagal bradycardia is often a temporary response to certain triggers (like pain or emotional stress) and does not typically require a permanent pacemaker.
Choice C reason:
Sinus tachycardia with rates faster than 80/min - Sinus tachycardia is a normal response to various factors, such as exercise, fever, or anxiety. It's not an indication for a permanent pacemaker.
Choice D reason:
Asymptomatic second-degree AV block - Asymptomatic second-degree AV block can be monitored and managed without a pacemaker, especially if the patient is not experiencing any symptoms or hemodynamic compromise. However, the type and severity of the second-degree AV block should be assessed by a healthcare provider to determine the appropriate course of action
Correct Answer is D
No explanation
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