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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because a sputum specimen should be placed in a sealed container and labeled with the client's name, date, and time before it is removed from the room. The container should be transported to the laboratory in a plastic bag.
Choice B Reason: This is incorrect because bed linens should be placed in a leak-proof laundry bag and handled with minimal agitation before they are removed from the room. The laundry bag should be closed securely and transported to the laundry facility.
Choice C Reason: This is incorrect because the nurse's stethoscope should be cleaned and disinfected with an alcohol wipe or a germicidal solution before it is removed from the room. The stethoscope should not be shared with other clients or staff.
Choice D Reason: This is correct because paper mask and gown are disposable items that are contaminated with the client's respiratory secretions and body fluids. They should be placed in a designated biohazard bag and disposed of properly before they are removed from the room.
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.
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