While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

Complete the intermittent suction of the nasopharynx.

Apply an oxygen mask over the client's nose and mouth.

Reposition the pulse oximeter clip to obtain a new reading.

Stop suctioning until the pulse oximeter reading is above 95%.

Answer and Explanation

The Correct Answer is A

Choice A reason: If the oxygen saturation remains stable during the procedure, it indicates that the suctioning is not adversely affecting the client's oxygenation, and the nurse can safely continue.

Choice B reason: Applying an oxygen mask is not necessary if the oxygen saturation is stable and within a safe range.

Choice C reason: Repositioning the pulse oximeter clip is only necessary if there is a concern about the accuracy of the reading, not when the reading is stable.

Choice D reason: There is no need to stop suctioning if the oxygen saturation is stable at 94%, as this is within the acceptable range for most clients.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Drinking 800 to 1,000 milliliters of fluid daily is below the recommended intake for most adults, which is generally around 2,000 milliliters per day to help prevent constipation.

Choice B reason: Oxycodone is an opioid that can actually lead to constipation, and its use should be carefully managed, not necessarily taken as scheduled for this purpose.

Choice C reason: Adding fat-containing foods is not a standard recommendation for preventing constipation; instead, a high-fiber diet is usually advised.

Choice D reason: Early and frequent ambulation is encouraged postoperatively to help stimulate bowel function and prevent constipation.

A. "Is there any particular reason why you think this is your fault?" B. "With surgery, your baby should have a full recovery." C. "This must be a very difficult time for you." D. "You did nothing wrong."

Correct Answer is C

Explanation

The correct answer is choice C. “This must be a very difficult time for you.”

Choice A rationale:

Asking the mother why she thinks it is her fault can make her feel defensive and does not provide the emotional support she needs at this moment. It may also imply that there could be a reason for her to feel guilty, which is not helpful.

Choice B rationale:

While it is important to provide hope and information about the prognosis, this response does not address the mother’s immediate emotional distress and feelings of guilt. It focuses on the future rather than acknowledging her current emotional state.

Choice C rationale:

This response is empathetic and acknowledges the mother’s feelings. It provides emotional support and validates her experience, which is crucial in helping her cope with the situation.

Choice D rationale:

Telling the mother she did nothing wrong is important, but it does not fully address her emotional distress. It is a factual statement that may not provide the comfort and understanding she needs at this moment.

View Question and Answer

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

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing postoperative teaching to a client on ways to prevent constipation. Which information should the nurse include?

Correct Answer is D

Explanation

The mother of a child born with Tetralogy of Fallot asks the nurse, "Why did this happen to my baby? What did I do wrong?" Which response by the nurse is most helpful?

Correct Answer is C

Explanation

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?

A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?

An older adult client returns to the clinic for chronic pain management after taking morphine sulfate 25 mg PO every 12 hours. The client reports taking the medication only when the pain was too severe to sleep. Which action should the nurse implement?

The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize that the client is at greater risk for the development of which complication?

The nurse is planning assignments for the staff on a medical-surgical unit. Which task should the nurse assign to the practical nurse (PN)?

A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. When caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?