A client has a PRN prescription for a nasal cannula at 2 to 3 L/minute. The client is wearing a nasal cannula at 2 L/minute and asks the practical nurse (PN) if it can be removed. Which client data is most important for the PN to obtain before responding to the client?
Apical heart rate.
Breath sounds.
Oxygen saturation.
Blood pressure.
The Correct Answer is C
Choice A reason: While the apical heart rate is important for overall health assessment, it is not the most critical data point to consider before deciding if a client can discontinue oxygen therapy. Oxygen saturation provides more direct information about the client's respiratory status.
Choice B reason: Breath sounds are important in assessing a client's respiratory condition, but they are not as immediately indicative of whether the client can safely discontinue using the nasal cannula. Oxygen saturation levels give a more precise measurement of the client's oxygen needs.
Choice C reason: Oxygen saturation is the most important data to obtain before responding to the client's request. It directly measures the percentage of oxygen in the client's blood, providing a clear indication of whether the client is receiving adequate oxygen while on the nasal cannula. Ensuring that the client's oxygen saturation is within a safe range is crucial before considering the removal of the oxygen support.
Choice D reason: Blood pressure is another vital sign that provides important health information, but it does not give a direct indication of the client's oxygenation status. Oxygen saturation is a more relevant measure when determining if the nasal cannula can be safely removed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Providing reassurance that hair loss is not usually permanent offers the client some comfort during a challenging time. Informing her that the color and texture may change when it grows back prepares her for potential differences in her hair's appearance post-chemotherapy. This response acknowledges the temporary nature of chemotherapy-induced hair loss while also being honest about the possibility of changes, which helps manage the client's expectations effectively.
Choice B reason: Stating that "people with cancer react differently to chemotherapy" is true, but it is not the most supportive or informative response. It may leave the client feeling uncertain and anxious about the outcome. Providing more specific information about hair regrowth, as in choice A, is more helpful in addressing the client's concerns and providing reassurance.
Choice C reason: While acknowledging that wigs are available is practical, focusing on the possibility that hair might not grow back can be disheartening for the client. It is important to offer hope and positivity where possible, and emphasizing the usual pattern of hair regrowth, as in choice A, is a more supportive approach. If the client does have concerns about wigs, this can be discussed separately.
Choice D reason: Indicating that hair regrowth depends on the amount of drug received is somewhat accurate but lacks the reassurance and positivity provided in choice A. It is important to give the client a clearer understanding that, in most cases, hair loss from chemotherapy is temporary, and hair will generally grow back. This helps alleviate some of the stress associated with the treatment.
Correct Answer is A
Explanation
Choice A reason: Smoking two packs of cigarettes a day is highly significant in planning the client's rehabilitation following a myocardial infarction. Smoking is a major risk factor for cardiovascular disease, and continuing to smoke can significantly hinder recovery and increase the risk of future cardiac events. Addressing this behavior is crucial for improving the client's long-term health outcomes. Smoking cessation should be a primary focus of the rehabilitation plan, and the client should be provided with resources and support to quit smoking, such as counseling, nicotine replacement therapy, or medications.
Choice B reason: Expressing a desire to change one's lifestyle is a positive and encouraging sign. It indicates the client's motivation to adopt healthier habits, which is essential for successful rehabilitation. However, while this is important, the immediate focus should be on addressing specific risk factors, such as smoking, that have a direct and significant impact on the client's recovery and future health. The desire to change is a valuable component of the rehabilitation process, but it should be coupled with targeted interventions to address critical behaviors like smoking.
Choice C reason: Drinking 1 to 2 glasses of red wine daily may have both positive and negative health implications. Moderate alcohol consumption has been suggested to have some cardiovascular benefits, but it can also pose risks, especially if not monitored. While this information is relevant to the client's overall lifestyle, it is not as immediately critical as addressing smoking, which has a well-documented and direct impact on cardiovascular health. The client's alcohol consumption can be discussed as part of the broader lifestyle changes during rehabilitation.
Choice D reason: Walking four city blocks to work each day indicates a level of physical activity that is beneficial for cardiovascular health. Encouraging regular physical activity is an essential part of the rehabilitation process. However, compared to the impact of smoking, this information is less critical in the immediate planning of the client's rehabilitation. The focus should be on eliminating harmful behaviors like smoking, while also promoting continued and possibly increased physical activity as part of a comprehensive rehabilitation plan.
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