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 atached 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

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.

CThe 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 B

Explanation

Choice A rationale:

Encouraging the client to exercise every day to eliminate bedtime wakefulness is not appropriate advice in this scenario. It oversimplifies the issue and may not address the underlying causes of the client's sleep difficulties. Additionally, excessive exercise close to bedtime may actually interfere with sleep.

Choice C rationale:

Asking the client for a description of the exercise schedule being followed is a reasonable action. It allows the nurse to gather information about the client's exercise routine and assess whether it might be contributing to the sleep difficulties. However, this alone may not fully address the client's concerns.

Choice D rationale:

Determining the amount of weight the client has lost since increasing activity is relevant to the client's overall health and progress toward weight loss goals, but it does not directly address the issue of sleep difficulties. Weight loss and improved sleep may not always have a direct cause-and-effect relationship.

A. “I should avoid foods that are high in vitamin K.”. B. “I should take this medication with food.”. C. “I should report any unusual bleeding or bruising to my provider.”. D. “I should avoid taking aspirin while taking this medication.”.

Correct Answer is A

Explanation

Choice A rationale:

The client's statement, "I should avoid foods that are high in vitamin K," indicates an understanding of the medication. Warfarin is an anticoagulant medication that works by inhibiting vitamin K-dependent clotting factors. Consistent intake of vitamin K-containing foods helps maintain a stable INR (International Normalized Ratio) and warfarin's effectiveness. Clients on warfarin should be educated about avoiding drastic changes in their vitamin K intake.

Choice B rationale:

Taking warfarin with food or on an empty stomach doesn't significantly impact its efficacy. Therefore, this statement is not indicative of the client's understanding of the medication.

Choice C rationale:

The statement "I should report any unusual bleeding or bruising to my provider" is important but doesn't specifically reflect an understanding of warfarin. It's a general caution for anyone taking anticoagulants.

Choice D rationale:

While it's important to avoid excessive use of medications like aspirin that can increase the risk of bleeding, this statement doesn't directly demonstrate an understanding of warfarin itself.

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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

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Explanation

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Correct Answer is A

Explanation

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