The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

Switch to a non-rebreather mask.

Remove the nasal cannula.

Increase the oxygen to 3 L/minute.

Verify the placement of the pulse oximeter.

Answer and Explanation

The Correct Answer is D

Choice A reason: Switching to a non-rebreather mask is not the immediate action to take. Non-rebreather masks deliver a high concentration of oxygen, typically reserved for severe hypoxia. The patient’s oxygen saturation is low, but not critically low. It’s important to first ensure the accuracy of the reading before escalating oxygen delivery methods.

Choice B reason: Removing the nasal cannula is not advisable. The patient is postoperative and may have impaired gas exchange due to anesthesia, pain, or decreased mobility. Removing the supplemental oxygen may worsen the patient’s hypoxemia and increase the risk of complications.

Choice C reason: Increasing the oxygen to 3 L/minute could be a potential action if the oxygen saturation reading is accurate and the patient’s condition does not improve. However, any changes to a patient’s oxygen therapy should be made under the guidance of a healthcare provider. It’s important to first verify the accuracy of the oxygen saturation reading.

Choice D reason: Verifying the placement of the pulse oximeter is the highest priority action. Before making changes to the oxygen flow rate, it’s important to ensure that the oxygen saturation reading is accurate. Incorrect placement or function of the pulse oximeter could lead to inaccurate readings.

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Free Nursing Study Resources

Correct Answer is ["2.5"]

Explanation

To find the volume of the solution needed, the nurse can use the formula:

Volume (mL) = Dose (mg) / Concentration (mg/mL)

Substituting the given values, we get:

Volume (mL) = 1 mg / 0.4 mg/mL

Simplifying, we get:

Volume (mL) = 2.5 mL

Therefore, the nurse should administer 2.5 mL of naloxone to give a dose of 1 mg.

A. Have the client hold a pillow over the abdomen to cough and deep breathe. B. Encourage the client to eat all of the meals that are sent. C. Offer fruit juice at least twice during both the day and evening shifts. D. Lower the bed prior to helping the client to move up in bed.

Correct Answer is D

Explanation

Choice A: Have the client hold a pillow over the abdomen to cough and deep breathe is not the most important instruction because it is not related to repositioning. This is a good practice to prevent respiratory complications after surgery, but it can be done at any time.

Choice B: Encourage the client to eat all of the meals that are sent is not the most important instruction because it is not related to repositioning. This is a good practice to promote nutrition and healing after surgery, but it can be done at any time.

Choice C: Offer fruit juice at least twice during both the day and evening shifts is not the most important instruction because it is not related to repositioning. This is a good practice to prevent dehydration and constipation after surgery, but it can be done at any time.

Choice D: Lower the bed prior to helping the client to move up in bed is the most important instruction because it reduces the risk of injury and falls for both the client and the UAP. This is a safety measure that should be done before any repositioning.

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The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse plans to administer naloxone 1 mg. The label of the 10 mL vial indicates that the drug concentration is 0.4 mg/mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["2.5"]

Explanation

A client who had surgery 3 days ago is sitting with head of bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

Correct Answer is D

Explanation

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