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 A

Explanation

A. Emergency: This type of assessment is rapid and focuses on identifying and treating life-threatening conditions immediately, such as profuse bleeding from a stab wound.

B. Time-lapse: This assessment compares current client data to previous data to assess progress, which is not appropriate for an acute, life-threatening situation.

C. Focused: While this is a detailed assessment of a specific problem area, an emergency assessment is needed first for immediate threats to life.

D. Initial: This is a comprehensive assessment typically conducted when a client first enters a healthcare setting, but in an emergency, the focus shifts to immediate life-saving measures.

A. Trust vs. mistrust B. Autonomy vs. shame and doubt C. Initiative vs. guilt D. Industry vs. inferiority E. Identity vs. role confusion

Correct Answer is A,B,C,D,E

Explanation

Trust vs. Mistrust (Birth to 1 year): In this stage, infants learn to trust or mistrust their caregivers and the world based on the consistency of care they receive.

Autonomy vs. Shame and Doubt (1 to 3 years): During this stage, toddlers learn to exercise will and to do things independently; failure to do so causes shame and doubt.

Initiative vs. Guilt (3 to 6 years): In this stage, children begin to assert control and power over their environment through directing play and other social interactions.

Industry vs. Inferiority (6 to 12 years): Here, children learn to read, write, and do things on their own. Peers and teachers become significant figures, and children strive to be competent and successful.

Identity vs. Role Confusion (12 to 18 years): Adolescents search for a sense of self and personal identity, through an intense exploration of personal values, beliefs, and goals.

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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?

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Naxlex Comprehensive Predictor Exams

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