A nurse is assisting with the care of a client in a PACU.

Exhibits
Which of the following actions should the nurse take during the management of oxygenation for this client? Select all that apply.

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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Rationale:

A. "You will need to report any temperature above 98 Fahrenheit after discharge.": Reporting a temperature above 98°F is unnecessary, as this is within the normal range. Fever is typically defined as a temperature over 100.4°F and may indicate infection if it occurs postoperatively.

B. "I'm sure you know that clients have self-esteem issues after having surgery.": Generalizing the client’s emotional response can be dismissive and discourages open communication. Emotional reactions to hysterectomy vary, so individual concerns should be explored respectfully.

C. "Your kidneys should produce about 20 milliliters of urine each hour after surgery.": Stating a urine output of 20 mL/hour reflects an inaccurate understanding of kidney function. Normal renal output is at least 30 mL/hour, and anything less may indicate hypoperfusion or renal impairment.

D. "Let me know if you would like to hear about non-sexual ways to connect with a partner after surgery.": Offering information while allowing the client to guide the discussion respects emotional boundaries and promotes holistic recovery. This also acknowledges the impact surgery may have on intimacy without making assumptions.

A. "Perform sponge baths until the baby's umbilical cord falls off." B. "Use an alkaline soap to bathe the baby." C. "Ensure the bath water is at least 96 degrees Fahrenheit." D. "Apply talcum powder daily after bathing in order to prevent diaper rash."

Correct Answer is A

Explanation

Rationale:

A. "Perform sponge baths until the baby's umbilical cord falls off.": This is the appropriate instruction because keeping the umbilical stump dry reduces the risk of infection and promotes natural detachment. Sponge baths help prevent water from soaking the cord area until it fully heals and separates.

B. "Use an alkaline soap to bathe the baby.": Alkaline soaps can irritate a newborn’s sensitive skin by disrupting the natural acidic pH balance. Mild, pH-neutral or hypoallergenic baby cleansers are recommended to maintain skin integrity.

C. "Ensure the bath water is at least 96 degrees Fahrenheit.": Bath water should be warm, around 98.6°F (37°C), which is close to body temperature. Setting a minimum like 96°F may be too low and uncomfortable, while overheating the water poses a burn risk.

D. "Apply talcum powder daily after bathing in order to prevent diaper rash.": Talcum powder is not recommended due to the risk of respiratory irritation if inhaled. Preventing diaper rash is better achieved through frequent diaper changes and the use of barrier creams.

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A nurse is assisting with the care of a client in a PACU. Exhibits Which of the following actions should the nurse take during the management of oxygenation for this client? Select all that apply.

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A nurse is assisting with the care of a client in a PACU.

Exhibits
Which of the following actions should the nurse take during the management of oxygenation for this client? Select all that apply.