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:

Obtaining a urine specimen for analysis is an important step in the assessment of the client with renal calculi. However, it is not the most immediate intervention when the client is experiencing severe flank pain and hematuria. Pain management should take precedence.

Choice B rationale:

This is the correct answer. Severe flank pain in a client with renal calculi is indicative of renal colic, which is typically excruciating. Administering a prescribed opioid analgesic is the priority to relieve the client's pain and distress.

Choice C rationale:

Straining the urine for the presence of stones is an essential nursing intervention to identify and collect any passed stones. However, it is not the most immediate action when the client is in severe pain. Pain management is the priority.

Choice D rationale:

Preparing the client for a prescribed computed tomography (CT) scan is an important diagnostic step to assess the location and size of the renal calculi. However, it is not the most immediate intervention when the client is in severe pain and distress. Pain management should come first.

A. “You can continue to take calcium supplements as long as you take them with food.”. B. “You should avoid taking calcium supplements while you are on tetracycline therapy.”. C. “You can take calcium supplements with tetracycline as long as you drink plenty of water.”. D. “You should take calcium supplements at least 2 hours before or after tetracycline.”.

Correct Answer is D

Explanation

Choice A rationale:

Tetracycline antibiotics can form insoluble complexes with calcium, reducing their absorption when taken together. Therefore, advising the client to continue taking calcium supplements with food while on tetracycline therapy is not recommended as it may decrease the effectiveness of the antibiotic.

Choice B rationale:

The nurse should advise the client to avoid taking calcium supplements while on tetracycline therapy. Calcium-containing products (such as supplements, dairy products, and antacids) should be taken at least 2 hours before or after tetracycline administration to minimize the interference with drug absorption.

Choice C rationale:

Taking calcium supplements with tetracycline, even with plenty of water, can still lead to reduced drug absorption due to the formation of insoluble complexes. Therefore, this advice is not appropriate.

Choice D rationale:

The nurse should recommend that the client take calcium supplements at least 2 hours before or after tetracycline. This approach ensures that the client receives the full therapeutic benefit of the antibiotic while still meeting their calcium needs separately.

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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 with renal calculi is experiencing hematuria and reports severe flank pain.Which intervention should the nurse implement first?

Correct Answer is B

Explanation

A nurse is administering tetracycline to a client who has acne vulgaris.The client tells the nurse that he usually takes calcium supplements with his meals.How should the nurse respond?

Correct Answer is D

Explanation

A nurse is reviewing the laboratory results of a client who is receiving intravenous unfractionated heparin.The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds.What are the appropriate nursing actions in this situation? Select all that apply.*.

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