Patient Data

Exhibits

What is the rationale for the order of supplemental oxygen 10 L/min via nasal cannula? Select the best answer.

To prevent hypoxia and tissue damage due to pneumonia.

To lower the blood pressure and reduce the workload of the heart.

To increase the oxygen saturation and improve the respiratory function.

To dilate the bronchioles and decrease the inflammation of the lungs.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Supplemental oxygen is given to the patient to prevent hypoxia and tissue damage due to pneumonia. Pneumonia is an infection that inflames the air sacs in one or both lungs, which may fill with fluid or pus, causing cough with phlegm or pus, fever, chills, and difficulty breathing. Hypoxia occurs when the body or a region of the body is deprived of adequate oxygen supply at the tissue level. It can cause serious damage to your heart, brain, and other organs. Hence, supplemental oxygen is administered to ensure that the patient’s tissues receive adequate oxygen.

Choice B rationale:

While supplemental oxygen can indirectly help lower blood pressure by improving oxygen supply and reducing strain on the heart, it is not primarily used for this purpose. Enalapril, which the patient is already taking, is an angiotensin-converting enzyme (ACE) inhibitor that is commonly used to lower blood pressure and reduce the workload of the heart.

Choice C rationale:

Supplemental oxygen does increase the oxygen saturation and improve respiratory function. However, this is a more general rationale for providing supplemental oxygen and not specific to this patient’s condition of pneumonia.

Choice D rationale:

Supplemental oxygen does not directly dilate the bronchioles or decrease inflammation in the lungs. Medications such as bronchodilators and corticosteroids are typically used for these purposes. In this case, supplemental oxygen is being used to prevent hypoxia and tissue damage due to pneumonia.

Nursing Test Bank

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Correct Answer is C

Explanation

The correct answer is choice C: Ensure that the call bell is easily accessible to the client.

Choice C rationale: Ensuring that the call bell is easily accessible empowers the client to promptly request assistance if needed during the night. This promotes safety and reduces anxiety, as the client can quickly contact the nurse if they experience an urgent need to use the restroom or require any other assistance during the night.

Choice A rationale: Reassuring the client that someone will check on him hourly may provide some comfort, but it does not directly address the client's issue of urinary frequency. Ensuring easy access to the call bell is a more targeted approach to managing the client's needs.

Choice B rationale: Placing fresh water and a glass within reach on the bedside table is a good practice to maintain hydration, but it does not directly address the client's urinary frequency issue.

Choice D rationale: Offering an evening snack and oral care is essential for the client's overall well-being, but it is not directly related to managing the client's urinary frequency at night. The primary focus should be on ensuring that the client can access assistance quickly when needed.

A. Tenderness. B. Musical and drumlike. C. Absent sounds. D. Pain.

Correct Answer is B

Explanation

Choice A rationale:

Tenderness is not considered a normal finding during percussion of the abdomen. Tenderness suggests an underlying issue or inflammation in the abdominal area, which requires further evaluation and investigation.

Choice B rationale:

Musical and drumlike sounds are considered normal findings during percussion of the abdomen. These sounds indicate the presence of air-filled structures like the stomach or intestines. Normal abdominal percussion sounds are tympanic, and they are characterized by a hollow, drum-like quality when the abdomen is tapped lightly. This finding suggests that there are no significant abnormalities in the abdominal area.

Choice C rationale:

Absent sounds during abdominal percussion are not considered normal and may indicate a potential problem. Absent sounds could be due to factors such as bowel obstruction or severe constipation, which require further assessment and intervention.

Choice D rationale:

Pain during abdominal percussion is not considered a normal finding. It indicates discomfort or tenderness in the abdominal area, which requires further evaluation to determine the underlying cause.

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Patient Data Exhibits What is the rationale for the order of supplemental oxygen 10 L/min via nasal cannula? Select the best answer.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When caring for an older male client with urinary frequency, which measure is most important for the nurse to implement to help the client prepare to go to bed for the night?

Correct Answer is C

Explanation

The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client?

Correct Answer is B

Explanation

A nurse is planning recreational activities for a group of patients who are receiving rehabilitation and restorative care. Which of the following factors should the nurse consider when selecting appropriate activities? (Select all that apply.).

A nurse is updating the plan of care for a client who has a pressure ulcer on the sacrum. Which of the following outcomes are appropriate for this client? (Select all that apply.)

A client is diagnosed with influenza A and is prescribed oseltamivir. Which of the following statements by the client indicates a need for further education?

A nurse is teaching a client who has a urinary tract infection (UTI) about trimethoprim/sulfamethoxazole. The client asks why he needs to take two antibiotics together. What should the nurse say?

When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).

The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A 5-year-old child with a history of a waddling gait and frequent falls is brought into the hospital for diagnostic testing. When explaining the diagnostic testing to the parents, the nurse should provide information based on which understanding of the underlying disease pathology?

Patient Data

Exhibits

What is the rationale for the order of supplemental oxygen 10 L/min via nasal cannula? Select the best answer.