A nurse is assisting with the care of a client in a PACU.

Exhibits
Which of the following actions should the nurse take during the management of oxygenation for this client? Select all that apply.

Examine the client's nail beds.

Place the client in the supine position.

Encourage client to perform deep breathing exercises.

Prepare to administer oxygen via Venturi face mask.

Add a humidifier to the oxygen device.

Answer and Explanation

Correct Answer : A,C,D

Rationale:

• Examine the client's nail beds: Assessing nail beds for cyanosis provides visual clues of hypoxia. This is a noninvasive, rapid method to evaluate tissue perfusion and oxygenation. The client's saturations are borderline low despite increasing oxygen.

• Place the client in the supine position: The supine position can reduce lung expansion and worsen hypoxia, especially after sedation. Elevating the head of the bed promotes lung expansion and better diaphragmatic movement.

• Encourage client to perform deep breathing exercises: Deep breathing helps expand alveoli and improves oxygen exchange. It may reduce the need for higher oxygen delivery if the hypoxia is due to shallow respirations after sedation.

• Prepare to administer oxygen via Venturi face mask: The client's O₂ saturation is dropping despite nasal cannula at 5 L/min. A Venturi mask delivers a more precise and consistent oxygen concentration, making it appropriate here.

• Add a humidifier to the oxygen device: Humidification is generally needed for oxygen above 4 L/min over long durations. This client has only been on oxygen for a short time post-procedure, so humidification is not urgently required.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Oxytocin: Oxytocin is a uterotonic agent used to stimulate or augment labor, not to stop it. In the case of preterm labor at 36 weeks, administering oxytocin would worsen the situation by increasing uterine contractions and promoting delivery, which is not the intended goal.

B. Misoprostol: Misoprostol is typically used to induce labor by softening the cervix and stimulating contractions. It is contraindicated in clients experiencing preterm labor, as it would enhance uterine activity and could lead to premature delivery.

C. Magnesium sulfate: Magnesium sulfate is used in preterm labor to provide neuroprotection to the fetus and may also help reduce uterine contractions. It is especially indicated when labor is expected before 32–34 weeks but may still be prescribed at 36 weeks depending on clinical judgment.

D. Indomethacin: Indomethacin is a tocolytic agent used to suppress preterm labor contractions, but it is generally used before 32 weeks due to the risk of premature closure of the ductus arteriosus. At 36 weeks, the risks may outweigh the benefits, so it is not the first-line option at this gestational age.

A. Thoroughly explain each procedure to the toddler. B. Allow the toddler to handle the equipment. C. Completely undress the toddler. D. Start the examination with routine immunizations.

Correct Answer is B

Explanation

Rationale:

A. Thoroughly explain each procedure to the toddler: Toddlers have limited cognitive ability to understand detailed explanations. Overexplaining may cause anxiety rather than reassurance, especially if unfamiliar medical terms are used.

B. Allow the toddler to handle the equipment: Allowing the toddler to touch and explore safe medical equipment, like a stethoscope, helps reduce fear and builds trust. This play-based approach fosters cooperation and makes the exam less intimidating.

C. Completely undress the toddler: Toddlers can feel vulnerable when fully undressed. It is more appropriate to remove clothing gradually, only as needed for each part of the examination, to ensure comfort and security.

D. Start the examination with routine immunizations: Beginning with painful procedures like injections can create fear and resistance, making the rest of the exam more difficult. Immunizations should be done at the end of the visit.

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

A nurse is assisting with the care of a client in a PACU. Exhibits Which of the following actions should the nurse take during the management of oxygenation for this client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is at 36 weeks of gestation and is in preterm labor. The nurse should expect a prescription for which of the following medications for the client?

Correct Answer is C

Explanation

A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about foods that are high in folic acid with a client who is at 8 weeks of gestation. Which of the following foods should the nurse recommend as the best source of folic acid?

A nurse in a long-term care facility is delegating care for a group of clients for the oncoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply)

A nurse is reinforcing teaching about home safety precautions with the parents of a 3-month-old infant. Which of the following instructions should the nurse include in the teaching?

A nurse is collecting data from a client who has alcohol use disorder and is experiencing withdrawal. Which of the following manifestations should the nurse expect?

The nurse has reviewed the Nurses' Notes and Vital Signs at 0900. Exhibits Complete the following sentence by using the lists of options. The client is most at risk for dropdown due to dropdown

A nurse is preparing to delegate client care to an assistive personnel (AP). Which of the following information should the nurse verify prior to delegation?

A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath. and a respiratory rate of 24/min. Which of the following actions should the nurse take?

A nurse in a psychiatric unit is admitting a client who has self-inflicted cuts on their forearms. Which of the following is a priority response by the nurse?

A nurse is assisting with the care of a client in a PACU.

Exhibits
Which of the following actions should the nurse take during the management of oxygenation for this client? Select all that apply.