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 B
Explanation
Rationale:
A. Encourage the client to increase fluid intake: Clients undergoing peritoneal dialysis often have fluid restrictions based on residual renal function and ultrafiltration goals. Increasing fluid intake without specific provider guidance may lead to fluid overload.
B. Obtain the client's weight: Daily weight measurement is essential in peritoneal dialysis to assess fluid removal effectiveness and detect signs of fluid retention or dehydration. Weight changes help guide dialysis fluid volume and concentration adjustments.
C. Palpate the access site for a thrill: A thrill is assessed in clients with an arteriovenous (AV) fistula or graft used for hemodialysis, not peritoneal dialysis. Peritoneal dialysis uses a catheter placed in the abdominal cavity, which does not produce a thrill.
D. Auscultate the access site for a bruit: A bruit is associated with blood flow through an AV fistula or graft used in hemodialysis. In peritoneal dialysis, the access is a soft catheter, and auscultation for a bruit is not applicable or expected.
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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