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 D

Explanation

Choice A rationale:

Observing body language and movement is a valuable method for assessing pain, but it may not provide a comprehensive understanding of the client's pain experience. Clients may have different ways of expressing pain, and verbal communication should also be considered.

Choice B rationale:

Identifying effective pain relief measures is relevant but does not assess the quality of the pain itself. It focuses on pain management rather than pain assessment.

Choice C rationale:

Providing a numeric pain scale is a useful tool for quantifying pain intensity, but it does not assess the quality of pain, which is essential for understanding the nature of migraine headaches.

Choice D rationale:

Asking the client to describe the pain is the most appropriate approach for assessing the quality of pain. It allows the client to express the characteristics of the pain, such as its location, intensity, duration, and any associated symptoms, which can aid in diagnosis and treatment planning.

A. “Antihypertensive drugs work by increasing the blood flow to my heart and kidneys.” B. “Antihypertensive drugs can lower my blood pressure by affecting different parts of my cardiovascular system.” C. “Antihypertensive drugs are safe to use with any other medications or supplements I might take.” D. “Antihypertensive drugs will cure my hypertension if I take them as prescribed.”.

Correct Answer is B

Explanation

Choice A rationale:

This statement is incorrect. Antihypertensive drugs typically work by reducing blood pressure through various mechanisms, such as dilating blood vessels, reducing blood volume, or affecting the heart's workload. They do not increase blood flow to the heart and kidneys.

Choice B rationale:

This is the correct answer. Antihypertensive drugs work by affecting different aspects of the cardiovascular system, such as reducing blood vessel constriction (vasodilation), decreasing blood volume, or slowing the heart rate. By affecting these components, they can lower blood pressure.

Choice C rationale:

This statement is incorrect. Antihypertensive drugs can interact with other medications or supplements, potentially causing adverse effects or drug interactions. It's essential for the client to inform their healthcare provider of all medications and supplements they are taking to ensure safe and effective treatment.

Choice D rationale:

This statement is incorrect. Antihypertensive drugs do not cure hypertension but help control it. Clients need to understand that they will likely need to take these medications long-term to manage their blood pressure effectively.

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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?

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