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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Cognitive dysfunction: This is a broad term that includes various types of cognitive impairment.

B. Alzheimer's disease: This is a specific type of dementia, but it doesn’t specifically describe the timing of confusion.

C. Sundowning syndrome: This term describes increased confusion and agitation in the late afternoon and evening. It’s commonly seen in individuals with dementia.

D. Night-time confusion: This is a general term and doesn't specifically relate to the characteristic pattern of sundowning.

A. The client will teach back information about safe crutch walking. B. The client will demonstrate safe crutch walking. C. The client will not lean on the crutches to support their body weight. D. The client will ambulate 5 feet in one day. E. The client will walk 10 feet by day 2. F. The client will walk 20 feet by day 3. G. The client will explain 4 principles of crutch safety. H. The client will explain how to keep crutches in safe condition.

Correct Answer is ["D","E","F"]

Explanation

A. The client will teach back information about safe crutch walking.This is an essential component of client education and ensures that the client understands how to use crutches safely. However, this statement does not include a specific time frame, making it not a timed SMART goal.

B. The client will demonstrate safe crutch walking.Demonstration of skills ensures the client can safely perform crutch walking techniques. However, without a specific deadline, it does not qualify as a timed component.

C. The client will not lean on the crutches to support their body weight.This statement reinforces proper crutch technique to prevent nerve damage (e.g., axillary nerve compression). However, it lacks a specific timeframe, so it is not a timed SMART goal.

D. The client will ambulate 5 feet in one day. This goal is specific, measurable, and time-bound as it defines both the distance (5 feet) and the timeframe (one day), making it a timed SMART goal.

E. The client will walk 10 feet by day 2. This goal provides clear progression, stating that the client should ambulate 10 feet within two days, making it specific, measurable, and time-limited.

F. The client will walk 20 feet by day 3. This builds on the previous goals, ensuring incremental progress in crutch walking and clear expectations within a set timeframe.

G. The client will explain 4 principles of crutch safety.This is a knowledge-based goal that ensures the client understands the fundamentals of crutch safety. However, no specific timeframe is provided, so it is not a timed component.

H. The client will explain how to keep crutches in safe condition.This supports long-term safety and maintenance of crutches but does not specify when the client should demonstrate this knowledge, making it not a timed SMART goal.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The adult child of an older adult calls the nurse practitioner to report that the parent is becoming very confused after dark. What is this type of confusion named?

Correct Answer is C

Explanation

Correct Answer is ["D","E","F"]

Explanation

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