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. 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.

A. Testing visual acuity B. Observing for facial symmetry C. Eliciting the gag reflex D. Checking the pupillary response to light

Correct Answer is D

Explanation

A. Testing visual acuity: This assesses cranial nerve II (Optic nerve).

B. Observing for facial symmetry: This assesses cranial nerve VII (Facial nerve).

C. Eliciting the gag reflex: This assesses cranial nerves IX and X (Glossopharyngeal and Vagus nerves).

D. Checking the pupillary response to light: This assesses cranial nerve III (Oculomotor nerve), which controls pupil constriction and eye movements.

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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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