A nurse is assisting with the care of a client in a PACU. Provider Prescriptions
1100:
Oxygen 2 to 5 L/min via nasal cannula to maintain oxygen saturation greater than 92%.
Which of the following actions should the nurse take during the management of oxygenation for this client?
Select all that apply.
Place the client in the supine position.
Prepare to administer oxygen via Venturi face mask.
Add a humidifier to the oxygen device.
Encourage the client to perform deep breathing exercises.
Examine the client's nail beds.
Correct Answer : C,D,E
When managing oxygenation for a client in a PACU, the nurse should take several actions. The nurse should add a humidifier to the oxygen device to help prevent dryness of the nasal passages¹. The nurse should also encourage the client to perform deep breathing exercises to promote oxygenation¹. Additionally, the nurse should examine the client's nail beds for signs of cyanosis, which can indicate inadequate oxygenation¹.
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Related Questions
Correct Answer is B
Explanation
An incident report is formal documentation used to report any unexpected or adverse events that occur during the course of patient care. It provides a record of the incident and helps identify areas for improvement in patient safety and quality of care. The incident report should include details about the error, the potential impact on the client, actions taken to address the error, and any necessary follow-up.
A nursing care plan is a document that outlines the client's nursing diagnoses, goals, interventions, and evaluations. It is not the appropriate place to document a medication error or incident.
The provider's progress notes are documentation made by the healthcare provider, typically documenting their assessments, diagnoses, treatment plans, and progress of the client. A medication error made by the nurse should not be documented in the provider's progress notes.
The controlled substance inventory record is a record used to track the dispensing and administration of controlled substances. While it is important to maintain accurate records of controlled substances, documenting a medication error in this record is not the appropriate place as it is primarily used for inventory management purposes
Correct Answer is A
Explanation
a. Maintain low-level lights in common areas.
When caring for a client with confusion and memory loss, it is important for the nurse to create a safe and comfortable environment for the client. Maintaining low-level lights in common areas can help to reduce confusion and disorientation¹.
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