The practical nurse (PN) observes a client's mouth and lips as seen in the picture. Which follow-up action is most important for the PN to take?
Ask about pain.
Provide mouth care.
Offer fluids.
Administer oxygen.
The Correct Answer is D
A. Ask about pain. This is not the most important action because pain is not the primary problem in this situation. Pain may or may not be present, but it does not address the underlying cause of cyanosis.
B. Provide mouth care. This is not the most important action because mouth care does not improve oxygenation. Mouth care may be helpful to prevent infection and promote comfort, but it is not a priority in this case.
C. Offer fluids. This is not the most important action because fluids do not increase oxygen levels in the blood. Fluids may be beneficial to prevent dehydration and maintain circulation, but they are not urgent in this scenario.
D. Administer oxygen. This is the most important action because oxygen is essential for cellular function and survival. Oxygen therapy can reverse hypoxia and improve the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Locate where in the body the pain occurs. - While important, this information is relevant for understanding the pain's origin but may not necessarily capture changes in pain intensity after administering analgesics.
B. Apply a pain scale to describe the intensity. - This is crucial to assess the effectiveness of the analgesic. Changes in pain intensity post-medication can indicate the efficacy of the intervention.
C. Ask about elements of the pain experience. - This encompasses various aspects of pain but might not directly measure the immediate impact of the analgesic.
D. Question the client about precipitating factors. - While helpful for understanding triggers, it may not be as immediately relevant for assessing the analgesic's effect.
Correct Answer is C
Explanation
A. Calling the charge nurse might be necessary, but the immediate action after a needlestick injury is to cleanse the affected area to minimize the risk of infection.
B. Observing the appearance of the injection site is important but not the first action following a needlestick injury.
C. Cleaning the finger with soap and water is the initial action to reduce the risk of infection following a needlestick injury.
D. Explaining the occurrence to the client is important but comes after taking care of the nurse's immediate health following a needlestick injury.
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