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 C
Explanation
A. Temperature of 39°C (102.2°F):
Fever typically causes an increase in heart rate, not bradycardia.
B. Hypoglycemia:
Hypoglycemia is more commonly associated with tachycardia, sweating, and tremors, not bradycardia.
C. Report of dizziness:
Bradycardia (HR <60/min) can lead to decreased cardiac output and cerebral perfusion, causing dizziness.
D. History of cigarette smoking:
Smoking is associated with cardiovascular disease but not specifically bradycardia.
Correct Answer is D
Explanation
A. Granulation tissue forming at the bottom of the wound bed:
Granulation tissue is associated with second intention healing, where the wound is open and heals from the base up.
B. Healing of the wound is prolonged:
First intention healing is typically faster and involves minimal tissue loss.
C. Wound is contaminated at the time of injury:
First intention healing usually involves clean, surgical wounds, not contaminated wounds.
D. Skin edges of the wound are sutured closed with edges that are well approximated:
This is characteristic of primary intention healing, where surgical or clean wounds are closed with sutures or staples.
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