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 B

Explanation

Choice A reason: While teaching alternative ways to manage pain is important, it does not address the immediate issue of the client not taking the medication as prescribed.

Choice B reason: The client should be instructed to take the medication as prescribed to maintain consistent pain control and prevent breakthrough pain.

Choice C reason: Advising the client to take the medication only with severe pain is contrary to the prescribed regimen and could lead to inadequate pain management.

Choice D reason: It is important to discuss the risks of long-term medication use, but the priority is to ensure that the client understands the importance of taking the medication as prescribed for effective pain management.

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

Correct Answer is D

Explanation

Choice A reason: Offering fruit juice is part of good nutrition and hydration but does not directly assist with the client's breathing difficulty.

Choice B reason: Encouraging the client to eat all meals is important for nutritional support, but it is not the most critical action related to the client's immediate respiratory comfort.

Choice C reason: Lowering the bed may be a safety measure but does not address the client's need for respiratory support.

Choice D reason: Having the client hold a pillow over the abdomen can help splint the chest while coughing, reducing discomfort and facilitating deep breathing, which is essential for a client with emphysema experiencing difficulty breathing.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?

Correct Answer is D

Explanation

The nurse receives a report that a patient with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?

The nurse observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?

While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, formed, and light brown. Which action should the nurse implement?

To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes but does not feel a pulsation. Which action should the nurse take next?

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?

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