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. C-reactive protein level is a general marker for inflammation and can indicate infection, but it does not provide specific information about the wound infection.
B. Serum albumin is important for assessing nutritional status and wound healing potential, but it does not directly address the acute issue of a possible wound infection.
C. Serum blood glucose level is significant, especially in clients with diabetes, as high glucose can impair healing and increase infection risk. However, it does not directly provide information about the infection itself.
D. Culture for sensitive organisms is the most relevant lab value to evaluate before reporting to the healthcare provider. It identifies the specific pathogens causing the infection and guides appropriate antibiotic treatment.
Correct Answer is B
Explanation
A. Reviewing the prognosis for the spouse does not address the immediate concern about the influenza vaccination’s impact on the spouse’s health.
B. Explaining that the influenza vaccination will actually help reduce the risk of transmission of influenza to the spouse undergoing chemotherapy addresses the client’s concern and provides accurate information.
C. Planning the vaccination for a day when the spouse is not receiving chemotherapy does not resolve the underlying issue of the vaccination’s effectiveness and safety.
D. Determining when the spouse will finish chemotherapy is not relevant to the immediate concern of the vaccination and its effects on the spouse’s health.
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