The practical nurse (PN) is completing a focused assessment on a client who is prescribed oxygen at 3 liters per minute by nasal cannula. Which assessment finding by the PN requires immediate action?
The flowmeter shows 1 liter of oxygen being delivered.
There is no humidifier attached to the delivery system.
The client is lying in a supine position in the bed.
The cannula is pressed snugly against the client's cheeks.
The Correct Answer is A
This finding requires immediate action, as it indicates that the client is not receiving the prescribed amount of oxygen, which can compromise the oxygenation and perfusion of the tissues. The PN should adjust the flowmeter to deliver 3 liters per minute of oxygen, and check for any leaks or kinks in the tubing.
The other options are not correct because:
B. The absence of a humidifier does not require immediate action, as it is not a critical component of the oxygen delivery system. A humidifier can help moisten the dry oxygen and prevent mucosal irritation, but it is not essential for oxygenation.
C. The supine position does not require immediate action, as it is not a contraindication for oxygen therapy. The client may prefer this position for comfort or rest, and it does not affect the oxygen delivery or uptake.
D. The snug fit of the cannula does not require immediate action, as it is not a problem for oxygen therapy. The cannula should fit snugly against the client's cheeks to prevent dislodgment or slippage, and it does not interfere with the oxygen flow or diffusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Obtain emergency help. - This is the most urgent action as the client is unresponsive, and getting emergency assistance is crucial to providing immediate care.
B. Feel for a carotid pulse. - While assessing the pulse is important, if the client is unresponsive, the first step is to get emergency assistance.
C. Bring a glucometer to the room. - This action might be relevant for assessing specific conditions, but in this scenario, the priority is to seek immediate emergency assistance.
D. Check the blood pressure. - Assessing blood pressure is important, but in the case of an unresponsive client, seeking emergency help takes precedence for immediate assistance and care.
Correct Answer is D
Explanation
A) Incorrect- While notifying the healthcare provider is an important step to take after an error, it's not the first action the nurse should take. The immediate concern is the client's safety and well-being, so assessing the client for any adverse effects of the incorrect dose is the priority.
B) Incorrect- Documentation is important, but it's not the first action to take after administering an incorrect medication dose. The nurse should prioritize assessing the client for any adverse effects and ensuring their immediate safety.
C) Incorrect- Completing an incident report is an important step to document errors and prevent future occurrences, but it's not the initial action to take. First, the nurse should focus on the client's well-being by assessing for adverse effects.
D) Correct- Assessing the client for any adverse effects is the immediate priority when an incorrect dose of medication has been administered. The nurse's first concern is the safety and health of the client. Once the client's condition has been assessed and stabilized, further actions can be taken, such as notifying the healthcare provider and completing incident reports.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.