RH has a history of COPD. The CNA checks his vital signs at the beginning of the shift and tells you that his pulse ox reading is 91%. What should the nurse advise the CAN does next:
Chart the reading at 91%, this is normal for a COPD patient.
Place a non-rebreather on the patient with high flow oxygen.
Call the doctor if the patient is declining.
Sit the patient up and have them breathe deep.
The Correct Answer is D
Sitting the patient up and encouraging deep breathing can help improve oxygenation and increase the pulse oximetry reading. This is a non-invasive intervention that can be implemented immediately to help improve the patient’s oxygen levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
AB+ blood type is known as the universal recipient because individuals with this blood type have both A and B antigens on the surface of their red blood cells, as well as the Rh antigen. This means that they can receive blood from donors of any ABO blood type (A, B, AB, or O) and Rh factor (positive or negative) without experiencing a transfusion reaction.
Therefore, in the case of a patient who will be needing a blood transfusion, if the nurse knows that the patient's blood type is unknown, it is ideal to give them AB+ blood type as it is considered the safest option.
Correct Answer is A
Explanation
The client's greenish-yellow sputum with a musty odor may indicate an infection, such as pneumonia or bronchitis, which can affect the client's lung function. By auscultating bilateral breath sounds, the nurse can assess for the presence of abnormal lung sounds, such as crackles or wheezing, which may indicate further respiratory compromise.
While obtaining a blood culture for tuberculosis (option b) may be appropriate in certain circumstances, the client's sputum color and odor do not necessarily indicate tuberculosis as the cause of their respiratory symptoms.
Requesting pulmonary function studies (option c) may also be beneficial in assessing the client's lung function, but this is not the priority assessment in this situation.
Finally, while documenting the findings (option d) is an important aspect of nursing care, it is not the priority action when the client is presenting with signs of compromised lung function.
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