NCLEX RN Prioritization Questions Related

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The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?

  • A. Oxygen saturation is 88%.
  • B. Blood pressure is 145/90 mm Hg.
  • C. Respiratory rate is 22 breaths/minute when lying flat.
  • D. Pain level is 5 (on a 0 to 10 scale) with a deep breath.
Correct Answer: A

Rationale: The correct answer is 'Oxygen saturation is 88%.' Following a thoracentesis, oxygen saturation should improve. A saturation of 88% suggests a potential complication like pneumothorax. While the other assessment findings are important, the priority is to address the low oxygen saturation to prevent further complications. High blood pressure and respiratory rate may also need attention, but the immediate concern is the oxygen saturation level. Pain level, though significant for the patient's comfort, takes lower priority compared to the potential life-threatening issue of hypoxia.