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 D
Explanation
Choice A Rationale: Cleansing the wound may be necessary, but the priority in this case is to assess for any retained foreign bodies, such as the nail, and potential structural damage, which can be done through an X-ray.
Choice B Rationale: The client's immunization history is not the priority when assessing and managing a wound like this.
Choice C Rationale: Dressing the wound may be necessary but should come after assessing for retained foreign bodies and potential structural damage.
Choice D Rationale: Requesting an X-ray is the priority action because it helps determine if the nail is still present and if there is any damage to deeper structures, such as bones or foreign body remnants.
Correct Answer is A
Explanation
Choice A Rationale: The nurse will include instructions on draining the bladder with a clean intermittent catheter at appropriate intervals to prevent urinary retention and complications. This should be done every 3 to 6 hours, depending on the amount of fluid intake and output.
Choice B Rationale: Decreasing fluid intake is not typically recommended for individuals with spinal cord injuries, as adequate hydration is important.
Choice C Rationale: Observing the urine for a foul odor is relevant to monitor for urinary tract infections, but it is not a preventive measure.
Choice D Rationale: Keeping an indwelling catheter in place at all times is not typically recommended due to the increased risk of urinary tract infections and other complications.
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