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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A nurse caring for a client who is 2 days postoperative following an above-the-knee amputation should encourage the client to use the overbed trapeze. This will promote independence and mobility by allowing the client to reposition themselves in bed and perform upper body exercises.
Maintaining abduction of the client's residual limb with a pillow can help prevent contractures, but it does not directly promote mobility.
Cautioning the client to avoid a prone position while in bed is appropriate to prevent pressure injuries and promote healing, but it also does not directly promote mobility.
Keeping a loose, absorbent dressing over the client's surgical site is important for infection control but does not promote mobility.
Correct Answer is A
Explanation
The nurse should identify the sudden increase in energy as the priority finding to report to the provider. This could be a sign of an emerging manic episode, especially if the client is taking an antidepressant alone without a mood stabilizer.
It may indicate a switch to a manic state or the development of bipolar disorder. The provider needs to be informed promptly so that appropriate assessment and interventions can be implemented to ensure the client's safety and well-being.
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