The nurse receives a new prescription to administer oxygen at 3 L/minute via nasal cannula to maintain an oxygen saturation between 90 and 100% for a client. The nurse obtains an oxygen saturation reading of 85%, and after repositioning the oximeter on a different finger, obtains a second reading of 87%. Which action should the nurse take next?

Place the client in a Trendelenburg position.

Securely place the prongs of the cannula in the nostrils.

Place the pulse oximeter on the client's earlobe.

Document the second reading in the client's record.

Answer and Explanation

The Correct Answer is B

Choice A reason: The Trendelenburg position is not indicated for increasing oxygen saturation and could be harmful, especially for clients with respiratory distress.

Choice B reason: Ensuring that the prongs of the nasal cannula are securely placed in the nostrils is important for effective oxygen delivery, especially if the oxygen saturation remains below the prescribed range.

Choice C reason: Placing the pulse oximeter on the client's earlobe is an alternative site for obtaining a saturation reading, but it does not address the issue of potentially inadequate oxygen delivery.

Choice D reason: While documentation is important, the nurse must first address the low oxygen saturation levels before documenting the readings.

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Correct Answer is C

Explanation

Choice A reason: Completing an admission assessment is typically the responsibility of a registered nurse (RN) due to the comprehensive nature of the assessment.

Choice B reason: Accessing a central venous line is usually within the scope of practice of an RN, not a PN, due to the complexity and potential complications associated with central lines.

Choice C reason: Reinforcing discharge teaching is an appropriate task for a PN, as it involves reviewing and ensuring the client understands the instructions already provided by the RN or healthcare provider.

Choice D reason: Initiating blood product infusions is generally the responsibility of an RN because of the critical nature of the task and the potential for adverse reactions.

A. Hand washing only needs to be performed when exiting the client’s room. B. This client requires contact and droplet precautions. C. A gown and gloves should be worn any time there is potential for contact with secretions. D. A mask should always be worn when in the client’s room. E. This client would require a private room if admitted.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Choice A reason: False: Hand washing should be performed not only when exiting the client's room but also before entering the room and after any direct contact with the client or potentially contaminated surfaces within the room.

Choice B reason: True : The client has been diagnosed with Respiratory Syncytial Virus (RSV), which is a highly contagious virus. It can spread through droplets in the air when an infected person coughs or sneezes, or by touching a surface that has the virus on it. Therefore, contact and droplet precautions are necessary.

Choice C reason: True: Gowns and gloves should be worn whenever there is a potential for contact with secretions, especially when dealing with a patient who has a contagious condition like RSV. This is part of standard precautions to prevent the spread of infection.

Choice D reason: True: A mask should always be worn when in the client's room because RSV can be spread through droplets in the air. This is part of droplet precautions.

Choice E reason: True: This client would require a private room if admitted because RSV is highly contagious. Isolation in a private room is one of the strategies used to prevent the spread of the virus.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning assignments for the staff on a medical-surgical unit. Which task should the nurse assign to the practical nurse (PN)?

Correct Answer is C

Explanation

Exhibits Chart Reviewed For each statement, click to indicate whether the statement is true or false.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?

When interviewing a client about sexuality/reproductive function, which is the best approach for the nurse to use?

A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

The nurse is preparing an in-service on the Health Insurance Portability and Accountability Act (HIPAA) violations. Which example should the nurse use to demonstrate a HIPAA violation?

After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?

An older adult client returns to the clinic for chronic pain management after taking morphine sulfate 25 mg PO every 12 hours. The client reports taking the medication only when the pain was too severe to sleep. Which action should the nurse implement?