A nurse is caring for a client who has pneumonia.
The client’s oxygen saturation is 85%. What is the first action the nurse should take?

Increase the client’s oral fluid intake.

Initiate humidification therapy.

Raise the head of the bed.

Encourage the client to cough and deep breath.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Increasing the client’s oral fluid intake is not the immediate action the nurse should take. While hydration is important, it does not directly address the client’s low oxygen saturation.
Choice B rationale
Initiating humidification therapy can help to thin secretions and improve oxygenation, but it is not the immediate action the nurse should take.
Choice C rationale
Raising the head of the bed is the first action the nurse should take. This position can help to improve lung expansion and oxygenation.
Choice D rationale
Encouraging the client to cough and deep breath can help to clear secretions and improve oxygenation, but it is not the immediate action the nurse should take.

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Correct Answer is C

Explanation

Choice A rationale
Massaging the site after injection is not recommended. It can cause the insulin to be absorbed more quickly than intended, which could lead to hypoglycemia.
Choice B rationale
Using cold insulin for injection to minimize site pain is not accurate. Insulin should be at room temperature when injected. Cold insulin can make the injection more painful.
Choice C rationale
Rotating the injection site is important to prevent lipodystrophy, a condition that causes abnormal fat deposits at the injection site. It also helps to keep insulin levels consistent.
Choice D rationale
Insulin is not absorbed most rapidly when injected in the thigh. The abdomen is actually the site where insulin is absorbed most quickly.

A. 1 tablet B. 2 tablets C. 3 tablets D. 4 tablets

Correct Answer is B

Explanation

Step 1 is to determine how many tablets to administer. The client needs 650 mg of aspirin and each tablet contains 325 mg. So, the calculation is 650 mg ÷ 325 mg/tablet.
Step 2 is to perform the calculation. The result is 2 tablets.

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A nurse is caring for a client who has pneumonia. The client’s oxygen saturation is 85%. What is the first action the nurse should take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is caring for a client who has pneumonia.
The client’s oxygen saturation is 85%. What is the first action the nurse should take?