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 client to perform deep breathing exercises.

Examine the client's nail beds.

Answer and Explanation

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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Correct Answer is A

Explanation

Whenever a medication error occurs, it should be documented in an incident report. The purpose of the incident report is to document the details of the event, including what happened, why it happened, and what was done to prevent it from happening again. Incident reports are not part of the client's medical record and are not used for disciplinary action. They are used for quality improvement and risk management purposes.

The nursing care plan is a document that outlines the client's nursing care needs and interventions. It is not the appropriate place to document a medication error.

The controlled substance inventory record is used to document the administration and dispensing of controlled substances. It is not the appropriate place to document a medication error.

The provider's progress notes document the provider's assessment, diagnosis, and treatment plan for the client. They are not the appropriate place to document a medication error.

A. Assume responsibility for making the client's decisions. B. Maintain a verbal no-harm contract with the client. C. Limit the client's social interactions. D. Encourage the client to be assertive.

Correct Answer is D

Explanation

Encouraging the client to be assertive is an important aspect of managing dependent personality disorder. It helps the client develop self-confidence, make independent decisions, and advocate for their own needs.

Empowering the client to express their opinions and assert their boundaries can contribute to their personal growth and reduce their reliance on others.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hours PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this alert care incident?

Correct Answer is A

Explanation

A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has bipolar disorder. The client yells at the nurse whenever medication changes are prescribed by the client's provider. The nurse should identify that the client is using which of the following defense mechanisms?

A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

A male nurse is assigned to care for an older adult female client. The client tells the nurse that she wants a female nurse to care for her. Which of the following statements should the nurse make?

A nurse is reinforcing teaching with a client who has a new prescription for atorvastatin. For which of the following adverse eﬀects should the nurse instruct the client to monitor and report to the provider?

A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for pain management. Which of the following statements by the partner indicates an understanding of the teaching?