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 C
Explanation
A. This response is too vague and does not provide reassurance or accurate education for the client.
B. While the amount and type of drug can influence side effects, this response does not directly answer the client’s concern about regrowth.
C. Hair typically grows back after chemotherapy, although changes in color or texture are common. This response provides realistic reassurance and accurate information.
D. Although offering wigs may be helpful, this response does not address the client’s direct concern about whether her hair will return.
Correct Answer is C
Explanation
A. Obliterating the entry could make the record look messy and might not meet documentation standards.
B. Notifying the charge nurse might be appropriate for major errors or if the policy requires it, but it might not be necessary for a simple correction like this.
C. Drawing a single line through the erroneous entry and inserting the correct information maintains the integrity of the chart and shows the correction clearly.
D. Charting the correct information in the next column might create confusion about the sequence of data and might not clearly indicate the correction made.
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