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.

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Correct Answer is C

Explanation

Rationale:

A. Projectile vomiting: Projectile vomiting is more commonly associated with pyloric stenosis in infants, not intussusception. While vomiting may occur in intussusception, it is typically bilious and not forceful or projectile in nature.

B. Periorbital edema: Periorbital edema is typically related to renal or allergic conditions such as nephrotic syndrome or severe allergic reactions. It is not associated with gastrointestinal issues like intussusception.

C. Stools that contain currant jelly-like mucus: Intussusception causes bowel telescoping, leading to obstruction and compromised blood flow. This results in stools containing blood and mucus, often described as “currant jelly,” which is a hallmark symptom of the condition.

D. Visible gastric peristaltic waves: Visible peristalsis is more indicative of pyloric stenosis, where there is hypertrophy of the pyloric muscle. It is not typically seen in cases of intussusception.

A. Deliver 2 L of oxygen via partial nonrebreather mask. B. Give epinephrine intramuscularly C. Administer diazepam PO. D. Notify the radiology department

Correct Answer is B

Explanation

Rationale:

A. Deliver 2 L of oxygen via partial nonrebreather mask: While oxygen can support airway function, it does not address the underlying cause of anaphylaxis. Airway closure due to an allergic reaction requires immediate pharmacologic intervention, not just oxygen delivery.

B. Give epinephrine intramuscularly: Epinephrine is the first-line treatment for anaphylaxis. It counteracts bronchoconstriction, airway edema, and hypotension by stimulating alpha and beta receptors, and should be administered immediately when signs of airway compromise are present.

C. Administer diazepam PO: Diazepam is used for anxiety or seizures, not for acute allergic reactions. It has no effect on reversing airway swelling or bronchospasm and would delay the appropriate emergency treatment needed in this situation.

D. Notify the radiology department: Contacting the radiology department is not relevant or urgent in this scenario. The client is experiencing a life-threatening reaction that requires immediate medical intervention, not communication with non-emergency services.

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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.

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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.