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 {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of Stroke as evidenced by Neurological defects and Garbled speech. The symptoms of facial drooping, garbled speech, and high blood pressure are common signs of a stroke. However, it’s important to get a professional medical diagnosis as soon as possible. Please seek immediate medical attention.
Choice A rationale:
Intoxication is a plausible explanation for the client’s symptoms, especially given the report of alcohol consumption. However, intoxication typically does not cause facial drooping, which is a common sign of neurological issues such as a stroke. Therefore, while intoxication may contribute to the client’s condition, it is not the most likely primary cause.
Choice B rationale:
Stroke is a medical emergency that often presents with facial drooping and garbled speech, both of which are observed in this client. A stroke occurs when blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. This can lead to brain cells dying in minutes. The client’s high blood pressure (210/98 mm Hg) is a significant risk factor for stroke. Normal blood pressure ranges from 90/60 mm Hg to 120/80 mm Hg.
Choice C rationale:
An allergic reaction could cause various symptoms, but it typically does not result in facial drooping or garbled speech. Common signs of an allergic reaction include hives, itching, redness, and swelling of the skin, as well as difficulty breathing in severe cases (anaphylaxis). There is no mention of these symptoms in the client’s presentation.
Choice D rationale:
Malignant hypertension is a possibility given the client’s extremely high blood pressure reading. This condition refers to severe hypertension that can quickly lead to organ damage. However, while it can cause neurological symptoms if it leads to a hypertensive crisis, the specific symptoms of facial drooping and garbled speech are more indicative of a stroke. In conclusion, based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of a stroke as evidenced by neurological defects (facial drooping and garbled speech). The client’s high blood pressure and reported alcohol consumption are both risk factors for stroke. Immediate medical intervention is crucial to minimize brain damage and potential complications.
Correct Answer is B
Explanation
Choice A rationale:
“I should take this medication with food to prevent stomach upset.” Rationale: This statement is not accurate for fluconazole. While some medications should be taken with food to reduce stomach upset, fluconazole is typically taken on an empty stomach. Taking it with food may reduce its absorption.
Choice B rationale:
“I should avoid drinking alcohol while taking this medication.” Rationale: This is the correct response. Fluconazole can interact with alcohol and may lead to increased side effects or reduced effectiveness of the medication. Therefore, it is essential to avoid alcohol while taking fluconazole.
Choice C rationale:
“I should use a barrier method of contraception while taking this medication.” Rationale: While it is generally a good practice to use barrier contraception during treatment for a fungal infection to prevent potential spread to a partner, this statement does not specifically address fluconazole's requirements or interactions.
Choice D rationale:
“I should stop taking this medication if I develop a rash.” Rationale: This statement is not entirely accurate. While it is important to monitor for skin rashes as they can be a sign of an allergic reaction, the decision to stop taking fluconazole should be made in consultation with a healthcare provider. It is not an automatic response to developing a rash.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.