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

1100:

Oxygen 2 to 5 L/min via nasal cannula to maintain oxygen saturation greater than 92%.

Which of the following actions should the nurse take during the management of oxygenation for this client?

Select all that apply.

Place the client in the supine position.

Prepare to administer oxygen via Venturi face mask.

Add a humidifier to the oxygen device.

Encourage the client to perform deep breathing exercises.

Examine the client's nail beds.

Answer and Explanation

Correct Answer : C,D,E

When managing oxygenation for a client in a PACU, the nurse should take several actions. The nurse should add a humidifier to the oxygen device to help prevent dryness of the nasal passages¹. The nurse should also encourage the client to perform deep breathing exercises to promote oxygenation¹. Additionally, the nurse should examine the client's nail beds for signs of cyanosis, which can indicate inadequate oxygenation¹.

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Correct Answer is C

Explanation

A.Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.

B.Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).

C.Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.

D.Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe..

A. Remove the absorbent pads from underneath the client. B. Place a pillow under the client's head. C. Place the client in high-Fowler's position. D. Remove the client's dentures

Correct Answer is A

Explanation

The nurse should remove the absorbent pads from underneath the client, place the client in a supine position with arms at the sides, close the client's eyes, and replace the client's dentures.

A pillow may be placed under the client's head for cosmetic purposes, but this is not a necessary action. High-Fowler's position is not appropriate for a deceased client.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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