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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Replace the drainage plug after releasing hand pressure on the device:
Doing this allows air into the reservoir, preventing the vacuum effect. Plug should be replaced while still compressed.

B. Empty the reservoir once per day:
Reservoirs should be emptied at least every shift or when half full, not just once a day.

C. Fully recollapse the reservoir after emptying it:
This restores negative pressure, allowing continuous drainage and wound healing.

D. Irrigate the tubing with sterile normal saline solution at least once every 8 hr:
Irrigating the tubing is not standard care for closed-wound drains and can introduce infection.

A. Use a cotton-tipped applicator to remove cerumen. B. Insert the probe snugly into the ear canal and press scan. C. Pull the pinna downward and backward. D. Hold the probe flat against the forehead and press scan.

Correct Answer is B

Explanation

A. Use a cotton-tipped applicator to remove cerumen:
Inserting objects like cotton-tipped swabs into the ear canal is unsafe and can cause damage; not recommended for clearing earwax before temperature measurement.

B. Insert the probe snugly into the ear canal and press scan:
This is the correct method to ensure an accurate tympanic temperature reading.

C. Pull the pinna downward and backward:
This is correct for children under 3 years, not for adults.

D. Hold the probe flat against the forehead and press scan:
This technique is for a temporal artery thermometer, not tympanic.

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A nurse is caring for a client who has an oxygen saturation of 88%. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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