A client was admitted 2 days ago with pneumonia. The client is now having chest pain. Vital signs are Temperature 37.2 C (98.9 F), Pulse 108, Blood pressure 160/90, respirator rate 24, and Oxygen Saturation 90%. What should the nurse do first?

Call another nurse for help

Give pain medication as ordered

Call the admitting healthcare provider

Tell client to remain calm

Apply oxygen via nasal cannula as ordered

Answer and Explanation

The Correct Answer is E

A. Calling another nurse for help is unnecessary unless additional assistance is required after initial interventions.
B. Giving pain medication as ordered may address the chest pain but does not address the immediate need for oxygenation.
C. Calling the admitting healthcare provider can be done later if symptoms do not improve, but the immediate priority is to improve oxygenation.
D. Telling the client to remain calm may help reduce anxiety but does not address the low oxygen saturation.
E. Applying oxygen via nasal cannula as ordered is the priority action to improve the client’s oxygen saturation and alleviate hypoxemia, which could be contributing to their chest pain.

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Correct Answer is A,E,D,F,C,B

Explanation

Unoxygenated blood flows from the body into the right atrium, then passes through the pulmonary artery to the lungs. After receiving oxygen in the lungs, blood flows back to the heart via the pulmonary vein into the left atrium. It then moves into the left ventricle and is finally pumped out to the body through the aorta.

A. cannula prongs are curved downward to follow natural curve of nasal passages B. pressure areas of tubing along the skin of the ears are padded C. oxygen flow rate meter is set to 10 L/min D. no smoking signs and no open flame signs are posted and clearly visible E. cannula tubing is adjusted under the neck for proper fit

Correct Answer is C

Explanation

A. Curved prongs fitting the nasal passages correctly is appropriate practice for comfort and effective delivery.
B. Padding pressure areas on the skin is a best practice to prevent skin breakdown and is indicative of proper care.
C. An oxygen flow rate of 10 L/min is excessively high for a nasal cannula, which typically accommodates 1-6 L/min; this indicates a need for further education on proper flow rates.
D. Posting clear no smoking and no open flame signs is essential for safety in oxygen therapy, reflecting good practice.
E. Proper adjustment of cannula tubing under the neck is necessary to ensure a secure fit without causing discomfort.

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A client was admitted 2 days ago with pneumonia. The client is now having chest pain. Vital signs are Temperature 37.2 C (98.9 F), Pulse 108, Blood pressure 160/90, respirator rate 24, and Oxygen Saturation 90%. What should the nurse do first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A,E,D,F,C,B

Explanation

When the nurse manager is evaluating the care of a client receiving oxygen through a nasal cannula, which finding indicates a need for more staff education about oxygen therapy?

Correct Answer is C

Explanation

A client was admitted 2 days ago with pneumonia. The client is now having chest pain. Vital signs are Temperature 37.2 C (98.9 F), Pulse 108, Blood pressure 160/90, respirator rate 24, and Oxygen Saturation 90%. What should the nurse do first?

Which statement by the nurse indicates the correct order of steps to take when performing a focused assessment of the respiratory system?

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