The practical nurse (PN) is caring for a client with a fractured left hip. The client develops tachypnea and deterioration in mental status. Which nursing intervention has the highest priority?
Perform an arterial stick to obtain a PaO2 level.
Obtain vital signs, including oxygen saturation.
Start oxygen at 2 liters nasal cannula.
Assess pain level and last pain medication given.
The Correct Answer is C
A. Performing an arterial stick to obtain a PaO2 level is important for diagnostic purposes but does not address the immediate need to improve oxygenation.
B. Obtaining vital signs, including oxygen saturation, is important but should follow the initiation of oxygen therapy to address the immediate threat to the client’s respiratory status.
C. Starting oxygen at 2 liters nasal cannula is the highest priority intervention to immediately improve the client’s oxygenation status and address the acute symptoms of tachypnea and altered mental status.
D. Assessing pain level and last pain medication given is important but secondary to addressing the client's acute respiratory symptoms.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Keeping the head of the bed elevated is not specifically related to the care of a PICC line. The elevation may be a general comfort measure but is not a specific instruction for PICC line management.
B. Changing the dressing over the PICC line insertion site is a sterile procedure that should be performed by a licensed nurse, not a UAP. This task requires specific training and adherence to infection control practices.
C. Feeding the client all meals to reduce arm movement is not necessary and may be overly restrictive. The UAP’s role does not include limiting the client's activity beyond reasonable measures.
D. Using the opposite arm for blood pressure measurement is the correct guidance. It prevents potential interference with the PICC line and helps avoid complications such as dislodgement or infection.
Correct Answer is D
Explanation
A. While postmenopausal use of herbal estrogen may be a risk factor for breast cancer, it is not as significant as having a family history of the disease.
B. A history of fibrocystic changes and a painful lump are not as strong a risk factor for breast cancer as a family history of the disease.
C. Being of normal weight, height, and having children at a younger age are generally considered protective factors rather than risk factors for breast cancer.
D. A non-tender lump combined with a family history of breast cancer (mother with breast cancer) is the most significant risk factor for developing breast cancer.
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