the nurse analyzes the results of a patients arterial blood gases abgs which finding would require immediate action
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Nursing Elites

NCLEX-RN

NCLEX RN Prioritization Questions

1. The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action?

Correct answer: D

Rationale: While all the values are abnormal, the low PaO2 level of 59 mm Hg indicates that the patient is at a critical point on the oxyhemoglobin dissociation curve. At this level, a small decrease in PaO2 can lead to a significant drop in oxygen saturation and compromise tissue oxygenation. Therefore, immediate intervention is necessary to improve the patient's oxygenation status. Choice A (HCO3 of 31 mEq/L) may indicate metabolic alkalosis or compensation for respiratory acidosis; however, it does not require immediate action in this scenario. Choice B (SaO2 of 92%) is slightly low but not critically low to require immediate action. Choice C (PaCO2 of 31 mm Hg) is within the normal range and does not indicate immediate danger to the patient.

2. Which of the following signs is NOT indicative of increased intracranial pressure?

Correct answer: D

Rationale: Increased intracranial pressure can lead to serious complications if not promptly addressed. Common signs of increased intracranial pressure include decreased level of consciousness, sluggish pupil dilation, abnormal respirations, and projectile vomiting. However, an increased heart rate is not a typical sign associated with increased intracranial pressure. It is important for healthcare providers to recognize these signs early to prevent severe consequences such as brain herniation.

3. When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next?

Correct answer: C

Rationale: In this scenario, the nurse observed carpal spasms in the patient's right hand, indicating a positive Trousseau's sign, which is associated with hypocalcemia. Patients with acute pancreatitis are at risk for hypocalcemia, hence the nurse should promptly check the calcium level in the chart to assess the patient's condition. Notifying the healthcare provider comes after confirming the calcium level. There is no indication to ask about arm pain or to retake the blood pressure, as the primary concern is addressing the potential hypocalcemia.

4. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to

Correct answer: B

Rationale: An occupational therapist from the community center would be the most appropriate referral for this client. Occupational therapists specialize in helping individuals improve fine motor skills, which are essential for tasks like drawing up insulin injections. A social worker typically focuses on psychosocial aspects, a physical therapist on physical mobility, and another client with diabetes would not have the professional expertise to address the client's specific needs related to insulin preparation.

5. A client has no pulse or respirations. After calling for help, what should the nurse's first action be?

Correct answer: B

Rationale: In a situation where a client has no pulse or respirations, the initial action recommended by the American Heart Association is to start high-quality chest compressions. This action helps maintain blood flow to vital organs such as the brain until normal heart rhythm is restored. Starting CPR with chest compressions before checking the airway and providing rescue breaths is crucial to improve outcomes. While establishing an airway and obtaining a crash cart are important steps in resuscitation, initiating chest compressions takes precedence to ensure oxygenated blood circulation. Starting with chest compressions applies to adults, children, and infants but not newborns.

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