A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?

Recheck the client's SaO, level after having the client cough and clear their throat.

Review the client's most recent Sao, level in the medical record.

Notify the charge nurse of the client's condon.

Check the client's medical records to see which medications were recently administered.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Recheck the client's SaO2 level after having the client cough and clear their throat is correct. This action is crucial to ensure the accuracy of the SaO2 reading. Sometimes, minor obstructions or secretions in the airway can momentarily affect the oxygen saturation readings. Having the client cough and clear their throat may help improve the SaO2 readings by clearing any temporary blockages.

Choice B Reason:

Review the client's most recent SaO2 level in the medical record is incorrect. While reviewing the client's history is important, the immediate priority is to verify the current SaO2 level for accuracy before taking further action.

Choice C Reason:

Notify the charge nurse of the client's condition is incorrect. While it might eventually be necessary to inform other healthcare team members, the immediate action should focus on rechecking the SaO2 level to ensure the client's current oxygen saturation status.

Choice D Reason:

Check the client's medical records to see which medications were recently administered is incorrect. Knowing the client's recent medications is important for assessment, but it may not directly address the current situation of shortness of breath and low oxygen saturation. Rechecking the SaO2 level takes precedence in this acute situation.

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Correct Answer is D

Explanation

Choice A Reason:

Chicken is incorrect. Chicken is a type of poultry and is a meat product. Lacto-vegetarians do not consume meat, including poultry, as part of their dietary choices.

Choice B Reason:

Clam chowder is incorrect. Clam chowder is a soup typically made with clams and often contains ingredients like broth or cream, which may not align with a lacto-vegetarian diet. It includes seafood, which is excluded in lacto-vegetarian dietary practices.

Choice C Reason:

Tuna fish is incorrect. Tuna fish is a type of seafood and is not consumed in lacto-vegetarian diets. Lacto-vegetarians exclude all types of fish and seafood from their diet and primarily consume dairy products along with plant-based foods.

Given that the client follows a lacto-vegetarian diet, the most appropriate food choice from the options provided would be:

Choice D is Reason:

Cheese is correct. A lacto-vegetarian diet includes dairy products but excludes meat and seafood. Cheese, being a dairy product, aligns with the lacto-vegetarian dietary pattern as it is derived from milk and fits within the dietary preferences of this individual.

A. Have the client sign an against medical advice form. B. Tell the client that the surgeon will prescribe restraints if they try to leave. C. Explain to the client that they cannot leave until the surgeon discharges them. D. Administer a sedative medication to the client.

Correct Answer is C

Explanation

Choice A Reason:

Have the client sign an against medical advice (AMA) form is incorrect. While this form allows patients to leave against medical advice after acknowledging the risks, it should be used after thorough discussion, ensuring the patient understands the consequences. In this case, the client is postoperative and might not have received clearance from the surgeon, so this option may not be appropriate without further assessment.

Choice B Reason:

Tell the client that the surgeon will prescribe restraints if they try to leave is incorrect. Threatening restraints is not a suitable or ethical approach. Using restraints should be a last resort for ensuring safety, especially if a patient is attempting to leave. It's crucial to communicate and engage in dialogue rather than resorting to threats or coercion.

Choice C Reason:

Explain to the client that they cannot leave until the surgeon discharges them is correct. This action prioritizes the safety and well-being of the client while also informing them of the necessary procedure before leaving the hospital. It's essential to communicate the discharge process and ensure that the client understands the potential risks of leaving without proper medical approval. This approach maintains respect for the client's autonomy while emphasizing the importance of following the medical protocol for a safe recovery.

Choice D Reason:

Administer a sedative medication to the client is incorrect. Using sedatives to prevent a patient from leaving is not ethically or medically appropriate unless there's a critical situation where the patient is a danger to themselves or others. Administering sedatives without proper justification or consent violates ethical principles and could potentially harm the patient.

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A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who follows a lacto-vegetarian diet. Which of the following food choices should the nurse recommend?

Correct Answer is D

Explanation

A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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