A nurse is caring for a client who has an oxygen saturation of 88%. Which of the following actions should the nurse take?
Ask the client to cough every 4 hr.
Decrease the head of the client's bed.
Encourage the client to take deep breaths.
Request a prescription for an opioid analgesic.
The Correct Answer is C
A. Ask the client to cough every 4 hr:
Coughing can help clear secretions, but doing so only every 4 hours is not sufficient for hypoxia. More immediate action is needed.
B. Decrease the head of the client’s bed:
Lowering the head of the bed reduces lung expansion and worsens oxygenation.
C. Encourage the client to take deep breaths:
Deep breathing improves alveolar expansion and oxygen exchange, which helps raise oxygen saturation.
D. Request a prescription for an opioid analgesic:
Opioids can depress respiratory drive, further lowering oxygen levels unless pain is clearly affecting breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hydrofiber dressing:
Hydrofiber dressings are designed for moderate to heavy exudate, not dry or non-exudative wounds.
B. Transparent-film dressing:
Transparent-film dressings are ideal for superficial, non-draining wounds like skin tears. They protect the area while allowing for oxygen exchange and visualization of the wound.
C. Alginate dressing:
Alginate dressings are highly absorbent and used for moderate to heavy exudating wounds, not for dry superficial tears.
D. Foam dressing:
Foam dressings are best for wounds with exudate. They are thicker and may not adhere well to superficial skin tears without drainage.
Correct Answer is B
Explanation
A. Restricting fluid intake:
Adequate hydration is important for wound healing. Restricting fluids does not prevent dehiscence and may hinder recovery.
B. Using a pillow to support the abdomen when coughing:
This is called splinting the incision. It reduces stress on the wound during coughing or movement, helping prevent dehiscence.
C. Encouraging early ambulation:
Early ambulation promotes recovery and prevents complications like DVT or pneumonia, but does not directly prevent wound dehiscence.
D. Administering high-dose corticosteroids:
Corticosteroids impair wound healing and increase the risk of dehiscence. They are not preventative.
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