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.

Answer and Explanation

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.

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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.

A. The colon is responsible for absorbing water and nutrients. I am now at high risk for ﬂuid and electrolyte imbalances. B. My colon is only responsible for sodium intake. I can eat more salt to ensure I am not deficient. C. The part of my colon that I have left will work overtime to prevent any deficiencies in my electrolytes. D. I am going to start drinking more Gatorade to prevent any imbalances from occurring.

Correct Answer is A

Explanation

The colon is responsible for absorbing water and nutrients.

I am now at high risk for ﬂuid and electrolyte imbalances. This statement demonstrates that the patient understands the function of the gastrointestinal tract in relation to ﬂuid and electrolyte balance. The colon plays an important role in absorbing water and electrolytes from digested food, and after a large portion of the colon has been removed, the patient may be at higher risk for ﬂuid and electrolyte imbalances.

Received message. The correct option is a. The colon is responsible for absorbing water and nutrients. I am now at high risk for ﬂuid and electrolyte imbalances. This statement demonstrates that the patient understands the function of the gastrointestinal tract in relation to ﬂuid and electrolyte balance. The colon plays an important role in absorbing water and electrolytes from digested food, and after a large portion of the colon has been removed, the patient may be at higher risk for ﬂuid and electrolyte imbalances.

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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:

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Naxlex Comprehensive Predictor Exams

The home care nurse visits a client with compromised lung function. The client has greenish yellow sputum with a musty odor. Which assessment is the priority for the

Correct Answer is A

Explanation

JD has been admited after a large portion of his colon has been removed due to cancer Which statement by the patient demonstrates that he understands the function of the Gastrointestinal tract as related to ﬂuid and electrolyte balance.

Correct Answer is A

Explanation

The nurse is caring for a client who recently had surgery on her left hip. What should be the priority teaching for the patient after surgery to prevent complications?

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The nurse observes that the client’s pulse oximetry is 89%. What is the priority nursing action?

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