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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Evaluating the return of the gag reflex is important for assessing a client's ability to protect their airway and for readiness to eat or drink after surgery. However, it is not the immediate priority when a client is repeatedly swallowing, which can indicate bleeding.
Choice B reason: Demonstrating relaxation techniques can be beneficial for managing pain and anxiety, but it does not address the immediate concern of potential postoperative bleeding in a client who is repeatedly swallowing.
Choice C reason: Using a penlight to assess the pharynx for bleeding is the priority action. Repeated swallowing after rhinoplasty can indicate bleeding, and assessing the pharynx allows the nurse to identify and address any postoperative hemorrhage promptly.
Choice D reason: Administering an intravenous analgesic per PRN protocol may help manage pain, but it is not the priority action. The primary concern is to check for potential bleeding, which is indicated by the repeated swallowing.

A. Return for urine culture and imaging. B. Use nonsteroidal anti-inflammatory drug (NSAID) for pain. C. Adhere strictly to medication regimen. D. Ensure effective perineal hygiene.

Correct Answer is C

Explanation

Choice A reason: Returning for a urine culture and imaging is an important part of follow-up care for a client with pyelonephritis. These tests can help ensure that the infection has been completely resolved and that there are no underlying structural abnormalities contributing to the condition. However, while follow-up appointments are crucial, the immediate priority for discharge instructions is to emphasize the importance of adhering to the prescribed medication regimen to ensure the effectiveness of the treatment.
Choice B reason: Using nonsteroidal anti-inflammatory drugs (NSAIDs) for pain can help manage discomfort associated with pyelonephritis. However, pain management is secondary to ensuring that the infection is effectively treated. While it is important to address the client's pain, reinforcing the need to follow the prescribed medication regimen takes precedence to ensure that the infection is adequately managed and prevented from worsening or recurring.
Choice C reason: Adhering strictly to the medication regimen is the most important instruction for the client. Ensuring that the client takes the full course of prescribed antibiotics is critical to effectively treating the pyelonephritis and preventing the development of antibiotic resistance or recurrent infections. Reinforcing the importance of completing the antibiotic course as directed helps ensure that the infection is fully eradicated and reduces the risk of complications.
Choice D reason: Ensuring effective perineal hygiene is important for preventing urinary tract infections (UTIs) and maintaining overall urinary health. While it is a relevant aspect of care, it is not the most critical instruction for the client at the point of discharge. The primary focus should be on the adherence to the medication regimen to treat the current infection and prevent further complications. Perineal hygiene practices can be reinforced as part of overall health education but are not the immediate priority compared to medication adherence.

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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?

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Naxlex Comprehensive Predictor Exams

Four hours after rhinoplasty, a client is swallowing repeatedly. Which priority action should the practical nurse (PN) take?

Correct Answer is C

Explanation

The practical nurse (PN) is caring for a client with pyelonephritis who is admitted for parenteral anti-infective therapy. Prior to discharge home with an oral medication regimen, which instruction is most important for the practical nurse (PN) to reinforce with the client?

Correct Answer is C

Explanation

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