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: Keeping the diaphragm in place for at least 4 hours after intercourse is a recommendation, but it does not address the specific concern of the client wanting to continue using her diaphragm postpartum.
Choice B Rationale: Having the client's provider refit her for a new diaphragm is the appropriate instruction after childbirth. The size and shape of the cervix can change postpartum, affecting the fit of the diaphragm.
Choice C Rationale: Using an oil-based vaginal lubricant can damage the diaphragm and is not recommended.
Choice D Rationale: Storing the diaphragm in sterile water after each use is not a standard practice. Proper cleaning and storage in a dry, cool place are recommended.
Correct Answer is A
Explanation
Choice A Rationale: Simple puzzles are appropriate activities for a client with severe Alzheimer's because they stimulate cognitive function and provide a sense of accomplishment.
Choice B Rationale: Board games are too complex and frustrating for a client with severe Alzheimer's, as they require memory, strategy, and social interaction.
Choice C Rationale: Dangling ribbons or a mobile are infantile and demeaning activities that do not respect the dignity and autonomy of the client.
Choice D Rationale: Drawing with crayons may be suitable for some clients with Alzheimer's, but it is not specific to the diagnosis and may not appeal to all clients.
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