A nurse is caring for a client who has an oxygen saturation of 88%. Which of the following actions should the nurse take?
Decrease the head of the client's bed.
Ask the client to cough every 4 hr.
Encourage the client to take deep breaths.
Request a prescription for an opioid analgesic.
The Correct Answer is C
The correct answer is choice c. Encourage the client to take deep breaths.
Choice A rationale:
Decreasing the head of the client’s bed can worsen oxygenation by compressing the lungs and reducing lung expansion, which is not advisable for a client with low oxygen saturation.
Choice B rationale:
Asking the client to cough every 4 hours can help clear secretions but does not directly address the immediate need to improve oxygen saturation.
Choice C rationale:
Encouraging the client to take deep breaths helps increase lung expansion and improve oxygenation, which is crucial for a client with an oxygen saturation of 88%.
Choice D rationale:
Requesting a prescription for an opioid analgesic is not appropriate in this context as opioids can depress respiratory function, potentially worsening the client’s oxygen saturation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer is: A. The client is asleep.
Explanation:
- A. The client is asleep. This is the correct answer because a client who is asleep is likely to have less pain than a client who is awake and restless. Opioid narcotics can also cause sedation, which can indicate effective pain relief.
- B. The client has an elevated blood pressure. This is incorrect because an elevated blood pressure can indicate increased pain, stress, anxiety, or other factors that are not related to pain relief. Opioid narcotics can also cause hypotension, which can indicate overdose or adverse effects.
- C. The client has an increased respiratory rate. This is incorrect because an increased respiratory rate can indicate increased pain, anxiety, hypoxia, or other factors that are not related to pain relief. Opioid narcotics can also cause respiratory depression, which can indicate overdose or adverse effects.
- D. The client is diaphoretic. This is incorrect because diaphoresis can indicate increased pain, fever, infection, or other factors that are not related to pain relief. Opioid narcotics can also cause sweating, which can indicate withdrawal or adverse effects.
Correct Answer is C
Explanation
The correct answer is choice C.
Choice A rationale:
Lecture is a teaching method in which the instructor delivers information to the learners without actively involving them. In this scenario, the nurse is asking the client to explain the procedure in their own words, which is a more interactive approach than a lecture.
Choice B rationale:
Role play involves simulated situations where the learner acts out specific roles. This method is not being used here, as the nurse is not asking the client to act out the procedure.
Choice C rationale:
Teach-back, also known as the "teach-back method" or "closing the loop," is a teaching method where the nurse asks the client to explain the information they've been provided in their own words. This approach helps assess the client's understanding and retention of the information and allows for clarification if needed. It is a patient-centered and effective method for ensuring that the client comprehends the instructions and can be considered as a form of active learning, enhancing retention and autonomy in healthcare decision-making.
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