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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A Rationale: Using antipsychotics around the clock is not an appropriate approach for managing Alzheimer's disease and may have adverse effects.

Choice B Rationale: "She will not be left home alone" indicates effective teaching because it emphasizes the importance of supervision and safety for a client with Alzheimer's who may be at risk of wandering or accidents.

Choice C Rationale: Applying a restraint to only one wrist is not an appropriate or effective strategy for managing Alzheimer's-related behaviors and may have ethical concerns.

Choice D Rationale: Placing rugs in the bathroom may create tripping hazards for a client with Alzheimer's. Effective teaching should focus on removing hazards rather than adding them.

A. Stage 3 B. Stage 2 C. Stage 1 D. Early stage

Correct Answer is D

Explanation

Choice A Rationale: Stage 3 of Alzheimer's disease is characterized by increased memory deficits, but the behavior of filling in information with made-up stories is more commonly associated with the earlier stages.

Choice B Rationale: Stage 2 of Alzheimer's disease involves progressive cognitive decline but may not necessarily manifest with the specific behavior described.

Choice C Rationale: Stage 1 of Alzheimer's disease typically has mild cognitive changes, but the behavior mentioned is more indicative of the later stages.

Choice D Rationale: The early stage of Alzheimer's disease may involve the emergence of confabulation, where clients fill in gaps in memory with fabricated stories or information.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse provides home safety education to the family of a client with moderate Alzheimer's. Which of the following statements made by the primary caregiver indicates effective teaching?

Correct Answer is B

Explanation

During a client interview, the nurse notices that the client often fills in information with made-up stories. Which stage of Alzheimer's disease will the nurse see this behavior?

Correct Answer is D

Explanation

A client with a new diagnosis of trigeminal neuralgia is receiving education to prevent triggering an acute onset. Which of the following will the nurse include in teaching?

A 45 year old client with a history of drug and alcohol abuse is admitted to the hospital. On day 2 the client has rapidly fluctuating moods and believes the King of England is in his room. How will the nurse document these findings?

When addressing the needs of a client with a newly diagnosed spinal cord injury, the nurse understands that which of the following are true about nutritional needs?

The nurse is providing care for a client who was placed in a halo brace 2 days ago because of a spinal cord injury. Which assessment is the first priority of the nurse?

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

A nurse is preparing a care plan for a client with a spinal cord injury. Which of the following is the highest priority for the nurse to implement?

A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?

A client arrives with respiratory muscle weakness, difficulty swallowing and abdominal pain. Which of the following reported by the client's husband is relevant to the client's manifestations?