A client who had surgery 3 days ago is sitting with head of bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

Have the client hold a pillow over the abdomen to cough and deep breathe.

Encourage the client to eat all of the meals that are sent.

Offer fruit juice at least twice during both the day and evening shifts.

Lower the bed prior to helping the client to move up in bed.

Answer and Explanation

The Correct Answer is D

Choice A: Have the client hold a pillow over the abdomen to cough and deep breathe is not the most important instruction because it is not related to repositioning. This is a good practice to prevent respiratory complications after surgery, but it can be done at any time.

Choice B: Encourage the client to eat all of the meals that are sent is not the most important instruction because it is not related to repositioning. This is a good practice to promote nutrition and healing after surgery, but it can be done at any time.

Choice C: Offer fruit juice at least twice during both the day and evening shifts is not the most important instruction because it is not related to repositioning. This is a good practice to prevent dehydration and constipation after surgery, but it can be done at any time.

Choice D: Lower the bed prior to helping the client to move up in bed is the most important instruction because it reduces the risk of injury and falls for both the client and the UAP. This is a safety measure that should be done before any repositioning.

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Correct Answer is D

Explanation

Choice A reason: Switching to a non-rebreather mask is not the immediate action to take. Non-rebreather masks deliver a high concentration of oxygen, typically reserved for severe hypoxia. The patient’s oxygen saturation is low, but not critically low. It’s important to first ensure the accuracy of the reading before escalating oxygen delivery methods.

Choice B reason: Removing the nasal cannula is not advisable. The patient is postoperative and may have impaired gas exchange due to anesthesia, pain, or decreased mobility. Removing the supplemental oxygen may worsen the patient’s hypoxemia and increase the risk of complications.

Choice C reason: Increasing the oxygen to 3 L/minute could be a potential action if the oxygen saturation reading is accurate and the patient’s condition does not improve. However, any changes to a patient’s oxygen therapy should be made under the guidance of a healthcare provider. It’s important to first verify the accuracy of the oxygen saturation reading.

Choice D reason: Verifying the placement of the pulse oximeter is the highest priority action. Before making changes to the oxygen flow rate, it’s important to ensure that the oxygen saturation reading is accurate. Incorrect placement or function of the pulse oximeter could lead to inaccurate readings.

Correct Answer is ["1"]

Explanation

To find the number of tablespoons, the nurse needs to convert the dose from milligrams (mg) to milliliters (mL), and then from milliliters to tablespoons. One tablespoon is equal to 15 mL.

The bottle label shows that 30 mg of dextromethorphan is equivalent to 15 mL of oral suspension. Therefore, the client needs to take 15 mL of oral suspension to get 30 mg of dextromethorphan.

Since one tablespoon is equal to 15 mL, the client needs to take one tablespoon of oral suspension with each dose.

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A client who had surgery 3 days ago is sitting with head of bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

Correct Answer is D

Explanation

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

Correct Answer is ["1"]

Explanation

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