The nurse is assessing an elderly client who has become confused since admission to the hospital two days ago.
Which assessment should the nurse complete first?
Oxygen saturation measurement.
Review of current medications.
Intake and output last 24 hours.
Use of hearing aids or glasses.
The Correct Answer is A
This is because the first priority for assessing an elderly client who has become confused since admission is to rule out hypoxia, which can cause or worsen delirium. Hypoxia can result from various conditions, such as pneumonia, pulmonary embolism, or heart failure.
Oxygen saturation measurement is a quick and non-invasive way to assess the oxygen level in the blood and identify hypoxia.
Choice B. Review of current medications is wrong because although medications can cause or contribute to confusion and delirium in older adults, they are not the most urgent assessment to perform.
Medications should be reviewed after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice C. Intake and output last 24 hours is wrong because although dehydration and electrolyte imbalance can cause or worsen confusion and delirium in older adults, they are not the most urgent assessment to perform.
Intake and output should be monitored after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice D. Use of hearing aids or glasses is wrong because although sensory impairment can cause or worsen confusion and delirium in older adults, it is not the most urgent assessment to perform.
The use of hearing aids or glasses should be ensured after ensuring adequate oxygenation and addressing other possible causes of confusion.
Normal ranges for oxygen saturation are 95% to 100% for healthy adults. Lower levels may indicate hypoxia or other respiratory or cardiac problems.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because aspirin can cause gastrointestinal bleeding, ulceration, and perforation as side effects. Tarry-colored stools indicate the presence of blood in the stool, which is a sign of bleeding in the upper gastrointestinal tract.
This is a serious condition that requires immediate medical attention.
Choice B. Swelling of the leg and knee is wrong because it is not related to aspirin use.
It may indicate inflammation, infection, or injury of the leg and knee, but it is not a priority symptom to report to the HCP.
Choice C. Right upper quadrant discomfort is wrong because it is not related to aspirin use.
It may indicate liver or gallbladder problems, but it is not a priority symptom to report to the HCP.
Choice D. Bruising around the injured knee is wrong because it is not related to aspirin use.
It may indicate trauma, bleeding disorders, or coagulation problems, but it is not a priority symptom to report to the HCP.
Normal ranges for bleeding time are 2 to 7 minutes. Normal ranges for PTT are 25 to 35 seconds. Normal ranges for liver enzymes are AST 10 to 40 U/L and ALT 7 to 56 U/L.
Correct Answer is B
Explanation
Pulse oximetry works by measuring the amount of light that passes through your finger and reaches a sensor on the other side.
The amount of light that is absorbed by your blood depends on how much oxygen it carries. Nail polish can block or reflect some of the light, making it harder for the pulse oximeter to get an accurate reading of your oxygen level.
Choice A is wrong because the color of your nailbed is not relevant for pulse oximetry.
The pulse oximeter does not measure the color of your nailbed, but the amount of light that passes through it.
Choice C is wrong because the sensor does not react with the nail polish causing an allergic reaction.
The sensor is a non-invasive device that does not touch your skin or nail polish directly.
Choice D is wrong because the chemicals in the nail polish do not cause falsely decreased readings of your oxygen level.
The chemicals in the nail polish do not affect the amount of oxygen in your blood, but only the amount of light that reaches the sensor.
Normal ranges for pulse oximetry vary depending on your health condition and altitude, but generally they are between 95% and 100%. If your pulse oximetry reading is lower than 90%, you may have hypoxia, which means your tissues are not getting enough oxygen.
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