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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Percussion: Percussion is typically performed before palpation. It helps to detect differences in density of abdominal contents, fluid presence, and gas patterns.
B. Auscultation: Auscultation is performed before any palpation or percussion to prevent altering bowel sounds. It is typically the second step after inspection.
C. Palpation: Palpation is used last during an abdominal assessment to prevent altering the characteristics of bowel sounds and to ensure that any tenderness or abnormal masses are identified after a thorough initial assessment. Palpation can cause changes in bowel sounds and tenderness.
D. Inspection: Inspection is always the first step in any physical examination. It allows for a visual assessment of the abdomen, looking for distension, asymmetry, and skin changes.
Correct Answer is D
Explanation
A. "I will begin 48 hr before the client's discharge." Waiting until 48 hours before discharge does not provide enough time for thorough planning, education, or addressing potential needs after discharge.
B. "I will begin once the client's insurance company approves discharge coverage." Discharge planning should not depend solely on insurance approval. It needs to be proactive and begin earlier to ensure comprehensive planning and education.
C. "I will begin once the client's discharge order is written." Starting discharge planning only after the discharge order is written does not allow adequate time for preparation and may result in rushed or incomplete planning.
D. "I will begin upon the client's admission to the facility."Discharge planning should start at admission. Early planning ensures that all aspects of post-discharge care are considered and allows ample time for education, coordination, and addressing potential barriers to successful discharge.
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