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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. This level indicates average blood glucose over the past 2-3 months and is higher than the target range (usually under 7% for many patients with diabetes). While this result suggests the need for adjustments in management, it is not an immediate emergency.
B. A random plasma glucose level of 205 mg/dL indicates hyperglycemia, but it is not typically considered an immediate danger unless accompanied by symptoms of hyperglycemia. This level would warrant further monitoring and possibly an adjustment in treatment, but it doesn't require urgent intervention.
C. A blood glucose level of 45 mg/dL indicates hypoglycemia, which is a critical condition that requires immediate action. Hypoglycemia can lead to symptoms such as confusion, seizures, or loss of consciousness, and it must be addressed quickly, usually with fast-acting carbohydrates.
D. While a fasting blood glucose level of 300 mg/dL indicates significant hyperglycemia, it does not require immediate action like hypoglycemia does. This level indicates a need for further management but is not acutely dangerous compared to a severely low blood glucose level.

A. Avoiding straining during bowel movement or bending at the waist. B. Keep rooms brightly lit C. Lie on your abdomen when in bed. D. Avoid lifting objects weighing more than 15 lbs.

Correct Answer is ["A","D"]

Explanation

A. Patients are often advised to avoid straining during bowel movements and bending at the waist to reduce intraocular pressure and the risk of complications after cataract surgery. This is crucial for promoting healing and preventing dislodgement of the lens.
B. While good lighting can be important for safety and visibility, patients are often advised to avoid excessively bright lights or glare, especially after surgery, as it can be uncomfortable and may not be beneficial during the recovery period. Patients may need to use softer lighting to avoid discomfort.
C. After cataract surgery, patients are typically advised to lie on their back or the non-operative side to avoid pressure on the eye that underwent surgery. Lying on the abdomen is not recommended and could pose a risk to the surgical site.
D. Patients are often instructed to avoid heavy lifting for a period after surgery to prevent increased intraocular pressure and potential complications. Lifting more than 15 lbs is generally discouraged during the initial recovery phase.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is ["A","D"]

Explanation

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