After assessing a client with deficits from a spinal cord injury, the nurse identifies the client's 02 saturation is 92%. Which of the following is the best first action by the nurse?
A Anticipate intubation
B Ask client to cough, then inhale and exhale deeply
C Insert an intravenous catheter
D Administer antihypertensives
The Correct Answer is B
Choice A Rationale: Anticipating intubation is not warranted solely based on an O2 saturation of 92% and without further assessment.
Choice B Rationale: Asking the client to cough, then inhale and exhale deeply is an appropriate initial action to improve oxygenation and assess the client's respiratory status.
Choice C Rationale: Inserting an intravenous catheter is unrelated to the client's O2 saturation and would not address the immediate concern.
Choice D Rationale: Administering antihypertensives is not indicated based on the O2 saturation level, and it may not be safe without further assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Rationale: Sedatives may not be the first choice for managing behavioral issues in clients with Alzheimer's disease, as they can increase confusion and fall risk.
Choice B Rationale: Antipsychotics may be considered in cases where behavioral issues pose a safety concern. They can help manage agitation, aggression, and other challenging behaviors.
Choice C Rationale: Cholinesterase inhibitors are used to treat cognitive symptoms of Alzheimer's disease but may not directly address behavioral issues.
Choice D Rationale: Serotonin reuptake inhibitors are typically used to manage mood disorders and may not be the first-line choice for behavioral issues in Alzheimer's disease.
Correct Answer is B
Explanation
Choice A Rationale: Keeping the client NPO until fitted for a halo vest is not a standard practice, and nutritional support should be initiated as soon as possible.
Choice B Rationale: A high-calorie, high-protein diet is typically started within 3 days of a spinal cord injury to support healing and prevent muscle wasting.
Choice C Rationale: High fiber and decreased protein are not the immediate dietary needs after a spinal cord injury. High protein intake is important for tissue repair.
Choice D Rationale: Low fiber and no protein would not be recommended 2 days after a spinal cord injury, as protein intake is crucial for healing and recovery.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.