A client is scheduled for a routine physical assessment at the neighborhood clinic. What should the nurse do when physically assessing the client's oxygenation status? Select all that apply.
Observe for signs and symptoms of respiratory distress.
Auscultate anterior and posterior lung fields.
Inspect the skin for pallor and cyanosis.
Assess the shape, expansion, and symmetry of the chest.
Observe rate, rhythm, and depth of respirations.
Correct Answer : A,B,C,E
A. Observe for signs and symptoms of respiratory distress.
B. Auscultate anterior and posterior lung fields.
C. Inspect the skin for pallor and cyanosis.
E. Observe rate, rhythm, and depth of respirations.
When assessing a client's oxygenation status, a nurse should observe for signs and symptoms of respiratory distress, such as dyspnea, wheezing, and use of accessory muscles. Auscultation of the anterior and posterior lung fields is important to identify any adventitious breath sounds such as crackles, wheezes or rhonchi that may indicate airway obstruction, fluid accumulation, or other respiratory abnormalities. Inspection of the skin is also important to detect pallor or cyanosis, which may indicate reduced oxygen levels in the blood. Lastly, observing the rate, rhythm, and depth of respirations can provide information on the adequacy of oxygen exchange in the lungs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer and Explanation
The correct answer is choice C, Read back the order to the physician.
After obtaining the physician's order over the phone, the nurse should read back the order to the physician to confirm accuracy and prevent medication errors.
This process ensures that the order is correctly transcribed and the right medication, dose, and route are given to the patient. Calling the pharmacy to check medication availability is not the nurse's responsibility, and initiating the prescription and administering the medication is inappropriate without confirming the order with the physician. Drawing up the medication into an appropriately labeled syringe before confirming the order with the physician is also inappropriate and can lead to medication errors. Therefore, reading back the order to the physician is the most appropriate action for the nurse to take.
Correct Answer is A
Explanation
The correct answer is choice A: "The JP drain uses negative suction to drain fluid from the wound." The purpose of the Jackson-Pratt drain is to remove excess fluid or blood from the surgical site. This drain uses a bulb-like container that creates negative pressure or suction, which allows the fluid to be removed from the wound into the container. It is important to maintain negative pressure to ensure that the drain is functioning properly. The nurse should also instruct the client on how to monitor the drainage and how often to empty the container, and to report any changes in the amount, color, or odor of the fluid to the healthcare provider.
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