A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?

Correct Answer: D

Rationale: Rationale: The correct answer is D) Administer oxygen. In a client with congestive heart failure experiencing severe shortness of breath, falling pulse oximetry, gray skin color, and pink frothy sputum, the priority is to address the impaired oxygenation by providing oxygen. Administering oxygen will help improve oxygen saturation levels and support the client's respiratory function, which is crucial in this emergent situation. Option A) Call the health care provider can delay immediate intervention. In a critical situation like this, the nurse must act promptly to stabilize the client's condition before seeking further orders. Option B) Check vital signs is important, but providing oxygen takes precedence in addressing the client's acute respiratory distress. Option C) Position in high Fowler's is a supportive measure but does not address the immediate need for oxygenation in a client with severe respiratory distress. In an educational context, this scenario emphasizes the importance of prioritizing interventions based on the client's condition. Nurses must quickly assess and intervene in acute situations to ensure the best outcomes for their patients. Understanding the critical nature of respiratory distress in clients with heart failure is essential for nurses working in medical-surgical settings.

Correct Answer: B

Rationale: In the scenario of a client experiencing a general tonic-clonic seizure, it is crucial for the nurse to place the client on their side (Option B) to prevent aspiration and ensure proper airway maintenance. Placing the client on their side helps in keeping the airway clear and allows any fluids to drain out of the mouth, reducing the risk of choking. This position also helps prevent injury during the seizure. The other options are incorrect for the following reasons: A) Holding the client's arms at their side may cause injury to the client or the nurse during the seizure. C) Inserting a padded tongue blade can lead to injury or obstruction of the airway and is no longer recommended in seizure management. D) Elevating the head of the bed is not appropriate during a seizure as it does not address airway protection or prevent aspiration. Educationally, it is vital for nurses to understand the correct management of seizures to ensure the safety and well-being of clients. Proper positioning and airway management are fundamental skills that nurses must possess to provide effective care during emergency situations like seizures. Training and practice in seizure management protocols help nurses respond efficiently and confidently in critical situations.

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to take first when assessing a client who has just undergone cardioversion and has respirations of 12 is to measure the pulse oximetry (Option C). This is the most appropriate initial action because it directly assesses the client's oxygen saturation level, which is crucial after a cardioversion procedure to ensure adequate oxygenation. Option A, trying to vigorously stimulate normal breathing, is not the correct immediate action as it may not address the underlying cause of the decreased respiratory rate and could potentially worsen the client's condition. Option B, asking the RN to assess the vital signs, may cause a delay in addressing the client's respiratory status directly. The nurse should first assess the oxygen saturation level independently. Option D, continuing to monitor respirations, is not the most appropriate initial action as the nurse needs to assess oxygenation status promptly after a cardioversion procedure to prevent any potential complications related to respiratory compromise. Educationally, this scenario highlights the importance of prioritizing actions based on the client's immediate needs following a medical procedure. It emphasizes the significance of prompt assessment and intervention to ensure client safety and optimal outcomes.

Correct Answer: B

Rationale: Advancing age by itself is not a risk factor. If that person has been exposed to a lot of sun there may be increased risk, but that information is not given here. There is a known genetic risk, with some cancers being seen to be present in families with low risk factors. Those with dark pigmentation develop skin cancer, but at a lower rate than those with low amounts of pigmentation. White collar jobs, which occur in offices and inside buildings, are a low risk for skin cancer.

Correct Answer: B

Rationale: Finding out about his childhood immunizations is of minor importance, given the prognosis. Getting information about whether Justin expressed the desire to donate his organs would be important at this time. Asking about the number of siblings might be a conversation opener, but is not of high importance to Justin's care. Previous hospitalizations and surgeries are irrelevant unless the organ donation is being considered, and this would then be important to learn.