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 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 A

Explanation

Displacement is a defense mechanism where a person redirects their emotional impulses, such as anger or frustration, from the original source to a less threatening or more accessible target. In this scenario, the client is redirecting their anger towards the nurse when medication changes are prescribed by the provider. The nurse becomes the target of the client's anger, even though the nurse is not directly responsible for the medication changes.

Conversion is a defense mechanism where psychological distress is expressed as physical symptoms or ailments.

Splitting is a defense mechanism where a person sees things as either all good or all bad, with no middle ground or ambivalence.

Sublimation is a defense mechanism where unacceptable impulses or behaviors are channeled into socially acceptable and constructive outlets.

A. A client who had a renal biopsy 3 hr ago and has pink-tinged urine B. A client who has a femur fracture and reports numbness of the toes C. A client who has cirrhosis and severe pruritus D. A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge

Correct Answer is B

Explanation

Numbness of the toes in a client with a femur fracture may indicate neurovascular compromise, which requires immediate attention.

It could be a sign of impaired circulation or nerve damage, and prompt assessment is needed to prevent further complications or permanent damage.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder. The client yells at the nurse whenever medication changes are prescribed by the client's provider. The nurse should identify that the client is using which of the following defense mechanisms?

Correct Answer is A

Explanation

A nurse is receiving change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?

Correct Answer is B

Explanation

A nurse is preparing to administer morphine 30 mg PO to a client who reports pain. Available is morphine solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

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