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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) Correct - Acute dystonic reactions are involuntary muscle spasms caused by certain medications, including antipsychotic drugs. These reactions can sometimes affect the muscles of the face and neck, including the larynx. Benztropine is an anticholinergic medication commonly used to treat acute dystonic reactions. It works by blocking certain neurotransmitters that contribute to muscle spasms, helping to relieve the symptoms.

B) Incorrect - Divalproex is an anticonvulsant medication primarily used to treat epilepsy and bipolar disorder. It is not the appropriate treatment for acute dystonic reactions. These reactions are usually caused by certain antipsychotic medications and are characterized by sudden and involuntary muscle contractions. Divalproex does not have the specific mechanism of action needed to alleviate the symptoms of acute dystonic reactions.
C) Incorrect - Isotonic crystalloid fluids are used for various purposes, such as fluid resuscitation, maintaining hydration, and balancing electrolytes. However, they are not a treatment for acute dystonic reactions. These reactions are neurological and musculoskeletal in nature and require medications with specific anticholinergic properties, like benztropine, to address the underlying issue.
D) Incorrect - Lorazepam is a benzodiazepine commonly used for anxiety, sedation, and seizure control. While it can have a relaxing effect on muscles, it is not the first-line treatment for acute dystonic reactions. Anticholinergic medications like benztropine are more appropriate because they directly counteract the neurotransmitter imbalances that lead to muscle spasms in these reactions.

A. Provide a regular diet tray B. Measure vital signs C. Apply oxygen 1 L/min D. Give Albuterol as ordered E. Perform pulmonary function test

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

Explanation

A) Incorrect - Providing a regular diet tray is important for the client's nutritional needs, but it is not as urgent as assessing vital signs or administering Albuterol in response to the client's acute symptoms.
B) Correct- This action is a priority after any assessment or intervention. Vital signs provide important information about the client's overall condition, including heart rate, blood pressure, respiratory rate, and oxygen saturation.
C) Incorrect - Applying oxygen is important, but its priority depends on the client's vital signs and oxygen saturation, which should be assessed first.
D) Correct- Administering Albuterol as ordered is crucial for addressing the client's acute breathing difficulty. Albuterol is a bronchodilator that helps alleviate asthma symptoms, and timely administration is essential.
E) Incorrect - Performing a pulmonary function test is valuable for assessing lung function, but it's not an immediate concern compared to addressing the client's breathing difficulty.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

Correct Answer is A

Explanation

Find patient data about a client below. After the nurse assesses the client, the physician writes orders. The nurse reviews the orders. Which 2 orders should the nurse complete first?

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

Explanation

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