A nurse is caring for a client who has an oxygen saturation of 88%. Which of the following actions should the nurse take?
Decrease the head of the client’s bed.
Encourage the client to take deep breaths.
Ask the client to cough every 4 hr.
Request a prescription for an opioid analgesic.
The Correct Answer is B
An oxygen saturation of 88% is below the normal range of 95-100%, indicating that the client may be experiencing hypoxia. Encouraging the client to take deep breaths can help increase their oxygen saturation level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Answer: B. A client who is unconscious.
A. A client who has a spinal cord injury.
While a spinal cord injury is serious and requires close monitoring, this condition does not immediately indicate that the client is unstable or at risk for life-threatening complications compared to an unconscious client. However, if there were signs of respiratory compromise or neurogenic shock, this client could be prioritized higher.
B. A client who is unconscious.
An unconscious client should be seen first because their condition may indicate a critical issue such as impaired airway, breathing, or circulation (ABC). Immediate assessment is needed to ensure the airway is clear, breathing is adequate, and circulation is stable, as these are life-threatening concerns.
C. A client who has peripheral vascular disease.
Clients with peripheral vascular disease (PVD) typically have chronic issues related to circulation in the limbs, which can cause pain and discomfort but are not usually immediately life-threatening. While important, this client is not the top priority compared to an unconscious client.
D. A client who has a new ankle sprain.
A new ankle sprain is painful and requires treatment, but it is not life-threatening. The nurse should address this client after ensuring the more urgent needs of other clients are met, such as the unconscious client who may require immediate interventions to preserve life.
Correct Answer is D
Explanation
The first step in the inflammatory response is the recognition of harmful stimuli by pattern recognition receptors (PRRs) on the surfaces of various cells, including immune cells and non-immune cells. PRRs recognize specific patterns associated with pathogens, damage-associated molecular patterns (DAMPs), and pathogen-associated molecular patterns (PAMPs), among others. This recognition leads to the activation of signaling pathways that promote the recruitment and activation of immune cells and the release of inflammatory mediators, such as cytokines and chemokines.
Once the PRRs recognize the harmful stimuli, inflammatory cells are activated, including neutrophils, macrophages, and dendritic cells. These cells then release inflammatory markers, such as C-reactive protein, which promote the recruitment and activation of more immune cells and further amplify the inflammatory response. Inflammatory pathways are also triggered, leading to the production of various inflammatory mediators and the activation of transcription factors that regulate the expression of genes involved in the inflammatory response.

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