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:
Vigorously strip the chest tube twice daily. The nurse should clarify the prescription to "vigorously strip the chest tube twice daily" with the provider. Stripping or milking a chest tube is generally not recommended, as it can cause damage to the tube and lead to complications. The movement of fluid and air in the chest tube should be allowed to occur naturally based on the patient's own respiratory effort.
Choice B Reason:
Assist the client out of bed three times daily - This is a reasonable activity for a client with a chest tube, as mobility and deep breathing can help prevent complications.
Choice C Reason:
Notify the provider when tiddling ceases - Monitoring for tiddling (fluctuations in the water seal chamber with respiration) and notifying the provider when tiddling stops is important, as it might indicate a potential issue with the chest tube placement or functioning.
Choice D Reason:
Administer morphine 2 mg IV bolus every 3 hr PRN for pain - Administering pain relief for the client is appropriate and helps manage their comfort. Pain control is important to encourage deep breathing and prevent complications related to shallow breathing due to pain.
Correct Answer is B
Explanation
Choice A Reason:
"This finding may indicate possible medication toxicity." - The red-orange colour change in bodily fluids from rifampin is not indicative of medication toxicity.
Choice B Reason:
"This is an expected adverse effect of this medication." Rifampin is an antibiotic commonly used to treat tuberculosis. One of the well-known side effects of rifampin is the discoloration of bodily fluids, including saliva, tears, sweat, and urine, to a red-orange colour. This is a harmless and expected adverse effect of the medication and is not a sign of toxicity or other serious concerns.
Choice C Reason:
"Your provider will prescribe a different medication regimen." - There is no need to change the medication regimen based solely on the colour change of bodily fluids. This is an expected effect of rifampin.
Choice D Reason:
"You will need to increase your fluid intake to resolve this problem." - Increasing fluid intake will not resolve the colour change caused by rifampin. The client should be educated about the benign nature of the side effects instead.
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