Nokea
A client experiencing acute dyspnea and diaphoresis reports anxiety and difficulty breathing. Vital signs include HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. What should the nurse prioritize?
- A. Notify the provider.
- B. Administer heparin via IV infusion.
- C. Administer oxygen therapy.
- D. Obtain a spiral CT scan.
Correct Answer: C
Rationale: In a client with acute dyspnea, diaphoresis, tachycardia, tachypnea, fever, and hypotension, the priority is to ensure adequate oxygenation. Administering oxygen therapy helps improve oxygenation levels and stabilize the client's condition. This intervention takes precedence over notifying the provider, administering heparin, or obtaining a CT scan, as oxygen therapy addresses the client's immediate need for respiratory support.
You may also like to solve these questions
A healthcare provider is caring for a group of clients. Which of the following clients is not at risk for pulmonary embolism?
- A. A client who has a BMI of 30
- B. A female client who is postmenopausal
- C. A client who has a fractured femur
- D. A client who has chronic atrial fibrillation
Correct Answer: B
Rationale: Postmenopausal status is not a significant risk factor for pulmonary embolism. Risk factors for pulmonary embolism include obesity (BMI of 30 or higher), immobility such as having a fractured femur, and conditions like chronic atrial fibrillation that increase the risk of blood clot formation. While postmenopausal status may be associated with other health risks, it is not directly linked to an increased risk of pulmonary embolism.
In the emergency department, a nurse is assessing a client involved in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. What action should the nurse take first?
- A. Obtain a chest X-ray.
- B. Prepare for chest tube insertion.
- C. Administer oxygen via high-flow mask.
- D. Initiate IV access.
Correct Answer: C
Rationale: In this scenario, the client is presenting with signs of respiratory distress, including absent breath sounds, dyspnea, and a low SaO2 level. The priority action should be to improve oxygenation by administering oxygen via a high-flow mask. This intervention aims to increase the oxygen supply to the client's lungs, helping to address the hypoxemia. Once oxygenation is optimized, further interventions, such as obtaining a chest X-ray, preparing for chest tube insertion, or initiating IV access, can be considered based on the client's condition and healthcare provider's orders.
When planning care for a client with severe acute respiratory distress syndrome (SARS), which of the following actions should not be included in the care plan?
- A. Administer antibiotics
- B. Provide supplemental oxygen
- C. Administer antiviral medications
- D. Administer bronchodilators
Correct Answer: A
Rationale: Severe acute respiratory distress syndrome (SARS) is caused by a virus, not bacteria, and antibiotics are ineffective against viral infections. Therefore, administering antibiotics would not be appropriate in the care plan for a client with SARS. The priority interventions for SARS include providing supplemental oxygen to improve oxygenation, administering antiviral medications to target the viral infection, and using bronchodilators to help with bronchospasm or airway constriction. Antibiotics are not indicated unless there is a secondary bacterial infection present.
A healthcare professional is assessing a client following a gunshot wound to the chest. For which of the following findings should the healthcare professional not monitor to detect a pneumothorax?
- A. Tachypnea
- B. Deviation of the trachea
- C. Bradycardia
- D. Pleuritic pain
Correct Answer: C
Rationale: Bradycardia, which is a slow heart rate, is not typically associated with a pneumothorax. In a pneumothorax, the presence of air in the pleural space can lead to lung collapse, causing symptoms such as tachypnea (rapid breathing), deviation of the trachea, and pleuritic pain. Monitoring for bradycardia may not be as relevant in this context as it is not a typical indicator of a pneumothorax.
A client has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse?
- A. ''I am allergic to morphine.''
- B. ''I take antacids several times a day.''
- C. ''I had a blood clot in my leg several years ago.''
- D. ''It hurts to take a deep breath.''
Correct Answer: B
Rationale: The correct answer is the statement 'I take antacids several times a day.' Antacids can alter the absorption of heparin, potentially affecting its effectiveness and increasing the risk of clot formation. This is a significant concern as it can impact the therapeutic outcome of heparin therapy. The other statements are not directly related to potential complications or interactions with heparin therapy.