The nurse is reviewing the female client's medical record.
Complete the following sentence by using the lists of options
The nurse should first address the client’s
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Rationale for correct choices
• Hypoxemia: The client has an oxygen saturation of 88% on room air and 89% on 2 L/min via nasal cannula, which indicates inadequate oxygenation. Hypoxemia is immediately life-threatening if not addressed promptly and takes priority over infection, hyperglycemia, or dehydration. Correcting oxygenation helps prevent tissue hypoxia and supports organ function.
• Oxygen saturation: The oxygen saturation measurement directly reflects the client’s hypoxemic status. Continuous monitoring of oxygen saturation is critical to evaluate the effectiveness of supplemental oxygen therapy and guide adjustments. This parameter is an objective indicator of respiratory compromise and provides the most immediate evidence for urgent intervention.
Rationale for incorrect choices
• Infection: The client has pneumonia evidenced by fever, productive cough with yellow sputum, and elevated WBC count. While infection requires prompt antibiotic therapy, it is not more immediately life-threatening than hypoxemia. Addressing oxygenation takes precedence before managing the underlying infection.
• Type 2 diabetes mellitus: The client’s blood glucose is elevated at 195 mg/dL, reflecting hyperglycemia. Although this requires monitoring and potential insulin therapy, it is not an immediate threat to oxygenation or organ perfusion. Hyperglycemia management is important but secondary to correcting hypoxemia.
• Dehydration: The BUN is slightly elevated at 25 mg/dL, which may indicate mild dehydration. The client is receiving IV fluids to support hydration. While fluid balance should be monitored, dehydration is not the most urgent issue compared with the client’s low oxygen saturation.
• BUN level: BUN elevation provides indirect evidence of fluid status or renal function but does not indicate immediate risk to tissue oxygenation. It is important for ongoing assessment but does not guide the initial urgent intervention.
• Blood glucose: Blood glucose reflects the client’s diabetic status and hyperglycemia. It is important to monitor and manage over time, but it does not provide the immediate evidence of hypoxemia that requires urgent correction.
• WBC count: Elevated WBC indicates infection and systemic inflammation. While this guides antibiotic therapy and monitoring, it does not address the immediate risk posed by hypoxemia. Prompt oxygen therapy takes priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The availability of religious facilities: A windshield survey involves direct observation of the community environment. Observing resources such as religious facilities, schools, parks, and stores provides information about community assets, social support, and infrastructure, which are key factors in assessing community health.
B. Influenza incidence rates for the current year: Incidence rates require access to public health records or databases, not visual observation. This type of epidemiological data is collected through statistical reports, not a windshield survey.
C. The leading cause of death for the prior year: Mortality data are obtained from health department statistics or vital records. This information cannot be gathered through direct community observation and therefore is not part of a windshield survey.
D. Individual perceptions about how residents interact: Perceptions and attitudes require interviews, surveys, or focus groups. A windshield survey captures observable, physical, and environmental characteristics, not subjective opinions, so this information would need other data collection methods.
Correct Answer is B
Explanation
A. Extend the client's legs above heart level: Elevating the legs may improve venous return but does not reduce tension on the abdominal incision or help prevent further dehiscence. It does not address the immediate concern of protecting the surgical site.
B. Place the client in a low-fowler's position: Positioning the client in a low-Fowler’s position (head of bed at 15–30 degrees) helps reduce intra-abdominal pressure on the incision and prevents further separation of the wound edges. This positioning supports comfort and minimizes strain while preparing for dressing application or further intervention.
C. Instruct the client to perform the Valsalva maneuver: Asking the client to strain or hold their breath increases intra-abdominal pressure, which can worsen dehiscence and increase the risk of evisceration. This action is unsafe and should be avoided.
D. Apply a dry gauze dressing to the incision: Applying a dry dressing alone does not protect the exposed tissue and may increase the risk of infection if evisceration occurs. The initial priority is to reduce tension on the wound by positioning before implementing sterile protective measures, such as a saline-moistened sterile dressing if necessary.
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