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.
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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Related Questions
Correct Answer is D
Explanation
The cervical cap should be left in place for a minimum of 6 hours after intercourse but should not exceed a total of 48 hours of continuous use. Leaving it in place for longer periods may increase the risk of toxic shock syndrome (TSS) and other potential complications. Using a cervical cap in combination with a spermicide is the recommended practice for maximizing its effectiveness. Spermicide helps immobilize or kill sperm, providing an additional barrier against pregnancy when used with the cervical cap.
Using the cervical cap during the menstrual cycle is not a recommended practice for contraception. The cervical cap is primarily used during sexual activity as a barrier method of contraception and is not specifically designed for use during menstruation.
While it is important for the provider to initially fit and size the cervical cap for the client, routine checks every 6 months are not necessary. However, it is still important for the client to regularly inspect the cap for any signs of damage or deterioration and replace it as needed.
Correct Answer is A
Explanation
a. Location of the identification tag on the client's body: This is essential information that should be included in the documentation. It ensures that the deceased person is properly identified and helps prevent any mix-ups during subsequent processes, such as transferring the body to the morgue or a funeral home.
b-While this information is important, it's typically documented by the physician on the death certificate and is not generally part of the nurse's postmortem documentation.
c-The last set of vital signs is not usually required for postmortem documentation. Postmortem documentation focuses on the condition of the body and identification rather than the final vital signs, which are often irrelevant after death.
d-Advance directives should be reviewed before death and guide the care provided, but they are not part of postmortem documentation. A copy of the client's advance directives may also be included in their medical record but is not typically included in postmortem documentation.
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