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A client is scheduled for a routine physical assessment at the neighborhood clinic. What should the nurse do when physically assessing the client's oxygenation status? Select all that apply.

Observe for signs and symptoms of respiratory distress.

Auscultate anterior and posterior lung fields.

Inspect the skin for pallor and cyanosis.

Assess the shape, expansion, and symmetry of the chest.

Observe rate, rhythm, and depth of respirations.

Answer and Explanation

Correct Answer : A,B,C,E

A. Observe for signs and symptoms of respiratory distress.

B. Auscultate anterior and posterior lung fields.

C. Inspect the skin for pallor and cyanosis.

E. Observe rate, rhythm, and depth of respirations.

When assessing a client's oxygenation status, a nurse should observe for signs and symptoms of respiratory distress, such as dyspnea, wheezing, and use of accessory muscles. Auscultation of the anterior and posterior lung fields is important to identify any adventitious breath sounds such as crackles, wheezes or rhonchi that may indicate airway obstruction, fluid accumulation, or other respiratory abnormalities. Inspection of the skin is also important to detect pallor or cyanosis, which may indicate reduced oxygen levels in the blood. Lastly, observing the rate, rhythm, and depth of respirations can provide information on the adequacy of oxygen exchange in the lungs.

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Correct Answer is A

Explanation

The correct answer is choice A: "The JP drain uses negative suction to drain fluid from the wound." The purpose of the Jackson-Pratt drain is to remove excess fluid or blood from the surgical site. This drain uses a bulb-like container that creates negative pressure or suction, which allows the fluid to be removed from the wound into the container. It is important to maintain negative pressure to ensure that the drain is functioning properly. The nurse should also instruct the client on how to monitor the drainage and how often to empty the container, and to report any changes in the amount, color, or odor of the fluid to the healthcare provider.

A. Right side B. High Fowler's position C. Supine, with feet flat D. Low Fowler's position E. Low Fowler's position

Correct Answer is B

Explanation

The correct answer is choice B, High Fowler's position. The High Fowler's position is the optimal position for nasogastric tube insertion as it allows for easy visualization and access to the nasal cavity, pharynx, and esophagus. The client should be in a semi-sitting position with the head of the bed elevated to at least 45-60 degrees. This position allows for better visualization and easier passage of the nasogastric tube through the nasal passages and into the esophagus. The other positions listed do not provide the optimal positioning for nasogastric tube insertion.

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A client is scheduled for a routine physical assessment at the neighborhood clinic. What should the nurse do when physically assessing the client's oxygenation status? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a post-operative client about the purpose of their surgical drain. The nurse should include in this teaching which of the following statements regarding the purpose of the Jackson-Pratt (JP) drain?

Correct Answer is A

Explanation

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion?

Correct Answer is B

Explanation

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