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

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

Add a humidifier to the oxygen device.

Place the client in the supine position.

Examine the client's nail beds.

Encourage client to perform deep breathing exercises.

Prepare to administer oxygen via Venturi face mask.

Answer and Explanation

Correct Answer : A,C,D

A. Add a humidifier to the oxygen device: Oxygen delivered at higher flow rates via nasal cannula can dry the mucous membranes, leading to discomfort and potential mucosal irritation. Adding a humidifier maintains mucosal moisture and improves tolerance of oxygen therapy.

B. Place the client in the supine position: Supine positioning can reduce lung expansion and promote atelectasis, especially in a post-sedation client. Encouraging upright or semi-Fowler’s positioning enhances ventilation and oxygenation.

C. Examine the client's nail beds: Assessing nail beds provides a quick visual indicator of tissue oxygenation and perfusion, allowing the nurse to evaluate the effectiveness of oxygen therapy and detect early hypoxemia.

D. Encourage client to perform deep breathing exercises: Deep breathing and incentive spirometry help prevent atelectasis, promote alveolar expansion, and improve oxygenation, particularly important after sedation and colonoscopy.

E. Prepare to administer oxygen via Venturi face mask: A Venturi mask is typically used for precise oxygen delivery in chronic respiratory disease. For a post-procedure client requiring 2–5 L/min to maintain SpO₂ > 92%, nasal cannula is appropriate, and escalation to a Venturi mask is not indicated at this stage.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Rationale:

• Weigh the adolescent each morning after voiding and before any intake: Daily weight monitoring is a standard intervention in inpatient treatment for anorexia nervosa. Weighing after voiding and before eating ensures accurate, consistent measurement of body weight trends, which is critical for assessing treatment progress and detecting rapid weight loss or gain.

• Monitor the adolescent for 1 hr after each meal: Post-meal monitoring is essential in anorexia nervosa care to prevent purging behaviors, such as vomiting or laxative use. Observation ensures the adolescent consumes the prescribed meals and supports safe refeeding, which is a core component of inpatient treatment protocols.

• Allow the adolescent to exercise for up to 1 hr per day: Exercise is generally restricted in the early phase of treatment for anorexia nervosa to prevent further energy depletion and cardiovascular strain. Permitting exercise could exacerbate malnutrition, weight loss, and electrolyte imbalance.

• Obtain an electrocardiogram: The adolescent exhibits bradycardia (heart rate 48/min), hypotension (80/50 mm Hg), and irregular heart rhythm, which increases the risk of cardiac complications. ECG monitoring is a routine intervention to assess cardiac status and detect arrhythmias associated with severe malnutrition.

A. Urticaria B. Hypertension C. Headache D. Tinnitus

Correct Answer is A

Explanation

A. Urticaria: The appearance of hives (urticaria) is a classic sign of an allergic reaction to medications, including vancomycin. It reflects histamine release and immune hypersensitivity, requiring prompt assessment and possible intervention.

B. Hypertension: Vancomycin does not typically cause elevated blood pressure as an allergic response. Blood pressure changes are more likely related to underlying conditions or infusion-related hemodynamic effects, not allergy.

C. Headache: Headache is not a typical manifestation of an allergic reaction to vancomycin. It may occur as a nonspecific adverse effect but does not indicate immune-mediated hypersensitivity.

D. Tinnitus: Tinnitus is associated with vancomycin ototoxicity at high doses or with prolonged therapy, not an immediate allergic reaction. It reflects potential auditory nerve or cochlear involvement rather than histamine-mediated responses.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has reviewed the Provider Orders from 2 weeks ago. For each potential intervention, click to specify if the intervention is expected or unexpected for the adolescent. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

The nurse is assisting in the administration of IV vancomycin to a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings indicate an allergic reaction to the medication?

Correct Answer is A

Explanation

The nurse has reviewed the Nurses Notes and Vital Signs from Day 2 at 0730 The nurse is reinforcing discharge teaching with the client. Select the 3 client statements that indicate the teaching was effective.

The nurse is reviewing the nurses' notes, admission assessment, vital signs, and laboratory data. Complete the following sentence by using the list of options. The nurse should first plan to dropdownand thendropdown.

A nurse is preparing to delegate client care to an assistive personnel (AP). Which of the following information should the nurse verify prior to delegation?

A nurse is giving change-of-shift report on a group of clients. Which of the following statements should the nurse make? (Select all that apply.)

A nurse is caring for an adolescent who requests screening for sexually transmitted infections (STI). The client asks the nurse. "Do you have to tell my parents?" How should the nurse respond to the adolescent?

A nurse is reinforcing client teaching about preventing stress injuries. Which of the following statements by the client indicates an understanding of teaching?

A nurse on a medical-surgical unit has received change-of-shift report for six clients. They have received additional information from assistive personnel (AP). Complete the following sentence by using the lists of options. The nurse should first collect data on dropdownfollowed bydropdown.

A nurse is reinforcing teaching with a client who has a new prescription for propranolol. The nurse should include which of the following as a potential adverse effect of this medication?

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

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