The patient complaints of dyspnea and the nurse is concerned the patient may need oxygen. What assessment will the nurse perform to determine if the patient needs supplemental oxygen?
Auscultate breath sounds.
Observe chest expansion
Measure capillary refill
Measure oxygen saturation
The Correct Answer is D
A. Auscultating breath sounds can provide valuable information about the presence of wheezing, crackles, or diminished breath sounds, which may indicate respiratory issues. However, while this assessment is important for understanding the underlying cause of dyspnea, it does not directly measure the patient's oxygenation status.
B. Observing chest expansion can help the nurse assess the mechanics of breathing and whether there are any restrictions in lung expansion. While this assessment is useful, it does not provide a clear indication of the patient's oxygen saturation levels or immediate need for supplemental oxygen.
C. Measuring capillary refill can give insights into peripheral perfusion and circulation, which can be affected by oxygenation. However, it is not the most direct or specific assessment for determining the need for supplemental oxygen in a patient with dyspnea.
D. Measuring oxygen saturation (using a pulse oximeter) provides a direct and objective assessment of the patient's oxygenation status. Normal oxygen saturation levels typically range from 95% to 100%. If the oxygen saturation is below the acceptable range (usually less than 92% in many clinical settings), this would indicate the need for supplemental oxygen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is a strong indicator of effectiveness. Both antacids and PPIs aim to reduce gastric acidity, which alleviates symptoms such as heartburn, regurgitation, and discomfort. A decrease in gastric distress suggests that the medications are successfully managing the symptoms of GERD.
B. Amylase is an enzyme primarily related to carbohydrate digestion, and its levels are not directly related to GERD or the effectiveness of antacids and PPIs. Normalizing amylase levels would not indicate the effectiveness of treatment for GERD, making this option irrelevant in this context.
C. While a decrease in vomiting may indicate an improvement in GERD symptoms, it is not the primary focus of treatment with antacids and PPIs. GERD primarily involves symptoms like heartburn and acid reflux rather than vomiting. However, if vomiting was due to severe reflux, improvement might indicate effectiveness.
D. Gastric motility refers to the movement of food through the gastrointestinal tract. While normal gastric motility can be beneficial, antacids and PPIs do not primarily aim to increase motility; their focus is on reducing acidity and managing reflux symptoms.
Correct Answer is D
Explanation
A. Cholecystitis, which is inflammation of the gallbladder, is not directly associated with diabetes mellitus. While people with diabetes may have other gastrointestinal issues, cholecystitis is not considered a long-term complication of diabetes.
B. Pancreatitis is inflammation of the pancreas and is not a common long-term complication of diabetes. While chronic pancreatitis can lead to diabetes (type 3c diabetes), it is not primarily caused by diabetes itself. Thus, it is not considered a typical long-term complication of diabetes mellitus.
C. Presbyopia is the age-related loss of near vision due to the hardening of the lens in the eye. While individuals with diabetes can experience eye problems, presbyopia is a normal part of aging and not specifically a long-term complication of diabetes.
D. Diabetic neuropathy is a well-known long-term complication of diabetes mellitus. It results from nerve damage caused by prolonged high blood sugar levels. Neuropathy can lead to various symptoms, including pain, tingling, and loss of sensation, particularly in the extremities.
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