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. Ongoing assessment: Ongoing assessments are continuous evaluations performed throughout the nurse's shift to monitor the client's status, response to interventions, and to adjust the care plan as needed.

B. Focused assessment: A focused assessment is targeted on a specific problem or area of concern, rather than a general or comprehensive evaluation.

C. Emergency assessment: An emergency assessment is rapid and focuses on identifying life-threatening conditions or urgent needs. It is not a routine, ongoing assessment.

D. Comprehensive assessment: A comprehensive assessment is an in-depth evaluation of the client's overall health status, usually performed upon admission or during initial evaluation. It is not typically repeated throughout the shift.

A. percussion B. auscultation C. palpation D. inspection

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.

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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

Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing?

Correct Answer is A

Explanation

When assessing the abdomen, which assessment technique is used last?

Correct Answer is C

Explanation

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