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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Reviewing the blood pressure measurement is not the primary concern here; the issue is that the UAP is using the incorrect arm for the measurement.
B. The blood pressure should be measured on the non-operative side. Measuring on the operative side can cause discomfort, potential injury, or interfere with the healing process.
C. Elevating the arm after recording the blood pressure is not a standard requirement post-mastectomy. The immediate concern is the proper measurement site for the blood pressure.
D. A manual blood pressure cuff is not required for accuracy in this situation; the key issue is to use the non-operative arm for measurement.

A. Administer the medication at least 30 minutes prior to the client's meals. B. Ensure peak and trough serum levels are collected with the third dose of medication. C. Observe the client for development of involuntary movements of the lips and tongue. D. Assess the skin daily for areas of ecchymosis or other signs of bleeding.

Correct Answer is D

Explanation

A. Administering ketorolac does not require specific timing in relation to meals. It can be given with or without food, but the key considerations are related to the drug’s effects rather than meal timing.
B. Ketorolac does not require peak and trough serum level monitoring. This practice is more relevant for medications with narrow therapeutic ranges or those requiring precise dosage adjustments, which is not the case for ketorolac.
C. Observing for involuntary movements of the lips and tongue is not a primary concern for ketorolac therapy. This is more relevant to medications like antipsychotics that can cause extrapyramidal symptoms.
D. Assessing the skin daily for signs of bleeding is crucial because ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding due to its effects on platelet function and gastrointestinal mucosa.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The practical nurse (PN) is assisting with the plan of care for a client who is receiving the nonsteroidal anti-inflammatory drug ketorolac for painful muscle spasms of the back. Which intervention should the PN include in the client's plan of care?

Correct Answer is D

Explanation

Exhibits Given the client's current treatment for fluid volume deficit, what condition(s) should the practical nurse (PN) monitor the client for? Select all that apply.

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the practical nurse (PN) to include in the assessment of this client?

The spouse of a hospitalized client asks the practical nurse (PN) for acetaminophen for a tension headache. Which action should the PN take?

A client with recurrent ascites from cirrhosis describes having no appetite or energy to the home health practical nurse (PN). What diet suggestions should the PN provide for the client? Select all that apply.

A 3-year-old male is being discharged after surgical correction of cryptorchidism. Which postoperative instruction is most important for the practical nurse (PN) to re-emphasize to the parents about the child's activities at home?

An older adult client of a long-term care facility is awake at 0330 and wandering down the hall in unbuttoned pajamas. Which intervention should the practical nurse (PN) implement?

In administering nystatin suspension to the gums of an infant with a candida infection, which approach should the practical nurse (PN) use?