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 ["B","C","D"]
Explanation
Client's pain rating on a scale of 1 to 10: This information helps assess the client's current pain level and determine the need for pain medication.
Time of the last administration of pain medication: This is important to avoid overdosing or administering pain medication too frequently. It helps ensure that pain medication is given at the appropriate time intervals.
Effectiveness of the last pain medication administered: Understanding whether the previous dose provided relief or not helps guide the choice of the next medication or dosage.
The other options are not directly related to the immediate decision of administering pain medication:
Height and weight of the client prior to admission may be part of the client's medical history but are not typically required information just before administering pain medication.
A history of pain medication use during the past year is important information but may be already documented in the client's medical records and not necessary to obtain immediately before administration.
Correct Answer is A
Explanation
This is the finding that the PN should report to the charge nurse because it indicates a possible complication of Guillain-Barre syndrome, which is autonomic dysfunction. This can affect the cardiac, respiratory, and gastrointestinal systems and cause life-threatening problems such as arrhythmias, hypotension, or respiratory failure. The PN should monitor the client's vital signs closely and report any abnormal changes.
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