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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
Choice A rationale:
Gathering information regarding how long it will take for the children to arrive is important but does not address the immediate need for information on the dying process.
Choice C rationale:
Offering to discuss the client's health status with each of the adult children is a good approach for involving them in their father's care but does not provide the immediate information the wife is seeking.
Choice D rationale:
Reassuring the spouse that the healthcare provider will notify when to call the children does not offer information about the dying process itself, which is what the wife is interested in understanding.
Correct Answer is C
Explanation
Choice A rationale:
Discuss the character of labor from endogenous vs. exogenous oxytocin. While it is important to educate the client about the difference between endogenous (naturally occurring) and exogenous (administered) oxytocin, this information may not address the client's primary concern. The client is refusing the prescribed oxytocin infusion and wants a "natural" delivery. Therefore, discussing alternative ways to support her birth plan is more pertinent.
Choice B rationale:
Ask the healthcare provider to discuss the issue with the client. Involving the healthcare provider in the discussion is a reasonable step, but it should not be the first action taken. The nurse can initiate a conversation with the client to explore her concerns and preferences before escalating the issue to the healthcare provider.
Choice C rationale:
Discuss alternative ways to support the client's birth plan. This is the correct choice because it directly addresses the client's refusal of the oxytocin infusion and desire for a "natural" delivery. Exploring alternative methods for inducing or facilitating labor in a way that aligns with the client's birth plan is essential.
Choice D rationale:
Explain the indications for induction related to post-term pregnancy. Explaining the indications for induction is important for educating the client about the medical reasons behind the prescribed treatment. However, this information may not immediately address the client's refusal of the oxytocin infusion. The nurse should first explore the client's concerns and preferences regarding her birth plan.
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