A nurse is caring for a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicate the intervention was effective?
Heart rate 110/min
Restlessness
Pink mucous membranes
Respiratory rate 28/min
The Correct Answer is C
Supplemental oxygen is administered to increase the amount of oxygen in the body and improve tissue oxygenation. The goal of this intervention is to improve the client's condition and reduce symptoms of hypoxia.
Options a, b, and d are all indicative of ongoing hypoxia and are not desirable outcomes. An increase in heart rate and respiratory rate and restlessness can be a sign that the client is still struggling to breathe and not getting enough oxygen.
Option c, pink mucous membranes, is indicative of improved tissue oxygenation. The mucous membranes, such as those in the mouth and nose, should be a healthy pink color when oxygen levels are adequate. Therefore, the nurse should identify pink mucous membranes as an indication that the intervention was effective in improving the client's hypoxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Localized warmth is a classic sign of inflammation and can indicate the presence of an infection or injury in the affected area. Sanguineous drainage is a type of wound drainage that consists of blood and is not a sign of inflammation. Palpable pedal pulses and full range of motion can provide information about the injury, but they are not specific to inflammation. Therefore, options b, c, and d are incorrect.
Correct Answer is C
Explanation
Answer: C. Place a surgical mask on the client when they leave their room.
Rationale:
A) Wear a surgical mask when within 0.6 m (2 ft) of the client.
While it is necessary to wear a surgical mask when in close proximity to a client on droplet precautions, the distance specified (0.6 m or 2 ft) is less than the standard recommended distance of 1 meter (3 feet). Therefore, this option is not fully aligned with best practices.
B) Move the client to a positive airflow room.
Positive airflow rooms are typically used for clients with immunosuppression or those who need protection from airborne pathogens, not for those on droplet precautions. This action is not appropriate for a client requiring droplet precautions.
C) Place a surgical mask on the client when they leave their room.
This action is appropriate and essential to minimize the risk of transmission of infectious agents to others when the client is moving outside their isolation area. The client wearing a mask is a key part of droplet precautions.
D) Remove fresh flowers from the client’s room.
While it may be necessary to remove fresh flowers in certain cases (such as for neutropenic clients), this is not specifically related to droplet precautions. Droplet precautions focus primarily on respiratory secretions and do not directly involve the presence of flowers.
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