A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?
Administer oxygen at 2 U/min.
Raise the head of the bed.
Encourage coughing and deep breathing
Administer prescribed analgesic medication
The Correct Answer is B
A. Administer oxygen at 2 L/min: Administering oxygen is important but should be done after positioning the client to improve natural ventilation.
B. Raise the head of the bed: Raising the head of the bed is the first action to take as it facilitates better lung expansion and improves ventilation. This can help increase the oxygen saturation more immediately and effectively.
C. Encourage coughing and deep breathing: Encouraging coughing and deep breathing is also beneficial to help clear secretions and improve lung function, but positioning the client for optimal breathing should be prioritized first.
D. Administer prescribed analgesic medication. Administering analgesics may be necessary for pain management, but it does not directly address the immediate need to improve oxygen saturation.
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Related Questions
Correct Answer is C
Explanation
A. Provide music as an environmental distraction: This might help in some contexts but is not typically necessary for preparing for a physical exam. Clear communication is more important.
B. Make sure the room temperature is cool: Older adults often have reduced ability to regulate body temperature and may find cooler environments uncomfortable. A comfortable room temperature is preferable.
C. Explain to the client what is about to happen: Clear explanations can reduce anxiety, increase cooperation, and ensure that the client understands the process, which is crucial for effective assessment and trust.
D. Inform the client that the provider will examine sensitive areas first: Sensitive areas are usually examined last to maintain comfort and build trust.
Correct Answer is B
Explanation
A. Document "impaired oxygenation" on the nursing care plan: While this may be appropriate based on assessment findings, it's premature to document without conducting a thorough assessment first.
B. Auscultate the chest for breath sounds: This is a critical component of assessing respiratory function, especially in a client with pneumonia, to identify abnormal breath sounds such as crackles or diminished breath sounds.
C. Collaborate with the client to form goals: Goal setting typically comes after assessment data is collected and analyzed.
D. Apply supplemental oxygen by face mask as needed: This action should be based on assessment findings indicating the need for oxygen therapy, not assumed without assessment.
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