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 ["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.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because occult blood is not visible to the naked eye. Waiting for observable blood may delay diagnosis and treatment of gastrointestinal bleeding.
Choice B Reason: This is incorrect because tarry black stool indicates upper gastrointestinal bleeding, which may not be related to the client's condition. Occult blood can be present in any color of stool.
Choice C Reason: This is correct because the nurse should obtain the specimen from the client's current bowel movement, regardless of its color or consistency. The test for occult blood detects hemoglobin in the stool, which may indicate bleeding anywhere along the gastrointestinal tract.
Choice D Reason: This is incorrect because contacting the healthcare provider before obtaining the specimen is unnecessary and may waste time. The nurse should follow the protocol for stool specimen collection and report any abnormal findings to the provider.
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