A nurse is assisting with the care of a client in a PACU.
Examine the client's nail beds.
Place the client in the supine position.
Encourage client to perform deep breathing exercises.
Prepare to administer oxygen via Venturi face mask.
Add a humidifier to the oxygen device.
Correct Answer : A,C,D
Rationale:
• Examine the client's nail beds: Assessing nail beds for cyanosis provides visual clues of hypoxia. This is a noninvasive, rapid method to evaluate tissue perfusion and oxygenation. The client's saturations are borderline low despite increasing oxygen.
• Place the client in the supine position: The supine position can reduce lung expansion and worsen hypoxia, especially after sedation. Elevating the head of the bed promotes lung expansion and better diaphragmatic movement.
• Encourage client to perform deep breathing exercises: Deep breathing helps expand alveoli and improves oxygen exchange. It may reduce the need for higher oxygen delivery if the hypoxia is due to shallow respirations after sedation.
• Prepare to administer oxygen via Venturi face mask: The client's O₂ saturation is dropping despite nasal cannula at 5 L/min. A Venturi mask delivers a more precise and consistent oxygen concentration, making it appropriate here.
• Add a humidifier to the oxygen device: Humidification is generally needed for oxygen above 4 L/min over long durations. This client has only been on oxygen for a short time post-procedure, so humidification is not urgently required.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Store ready-to-feed formula at room temperature for up to 4 hours.": Ready-to-feed formula should be used promptly or refrigerated if not used immediately. Leaving it at room temperature for up to 4 hours increases the risk of bacterial growth and contamination.
B. "Warm the bottle of formula by immersing it in a container of warm tap water.": This is a safe and recommended method to gently warm formula without overheating or creating hot spots that could burn the infant’s mouth.
C. "Keep open cans of concentrated formula uncovered and refrigerated.": Open cans of concentrated formula should always be covered to prevent contamination and should be refrigerated promptly after opening.
D. "Discard any formula left in the bottle within 2 hours after beginning feeding.": Formula left in the bottle after feeding should be discarded within 1 to 2 hours to prevent bacterial growth that can cause illness in the infant. This practice helps ensure feeding safety.
Correct Answer is C
Explanation
Rationale:
A. Dress the newborn in a warm gown when placing them next to the parent's skin: Skin-to-skin contact, not clothing layers, is the priority for thermoregulation in the first hours after birth. A warm gown may interfere with skin contact and reduce the effectiveness of heat transfer from parent to newborn.
B. Delay the newborn's feedings until their temperature is stabilized: Early feeding is encouraged for newborns to promote bonding, glucose stabilization, and warmth. Feeding should not be delayed, as it can help the baby generate heat through metabolism.
C. Postpone the newborn's initial bath: A newborn’s bath should be delayed until their temperature is stable to prevent further heat loss. Bathing can cause evaporation-related cooling, which may worsen mild hypothermia in a newborn during the early hours of life.
D. Place the swaddled newborn under a radiant warmer: Swaddling under a radiant warmer interferes with direct heat transfer. The newborn should be unclothed (except for a diaper) under the warmer to ensure effective warming through radiation.
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