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.
Ask the client to cough every 4 hr.
Encourage the client to take deep breaths.
Request a prescription for an opioid analgesic.
The Correct Answer is C
Choice A rationale
Decreasing the head of the bed or placing the client in a supine position can negatively impact respiratory effort by allowing abdominal organs to push against the diaphragm. This reduces lung expansion and can further lower oxygen saturation from 88 percent. For a client with low oxygen levels, the nurse should instead elevate the head of the bed to a semi-Fowler's or high-Fowler's position. This maximizes thoracic cavity space and improves the efficiency of gas exchange.
Choice B rationale
Asking the client to cough every 4 hours is an infrequent intervention that may not be sufficient to address an acute oxygen saturation of 88 percent. While coughing helps clear secretions, a four-hour interval is too long for a client currently experiencing significant desaturation. Immediate nursing actions should focus on improving current ventilation and oxygenation. Coughing and deep breathing are more effective when performed more frequently, such as every hour while awake, to prevent atelectasis.
Choice C rationale
Encouraging the client to take deep breaths is a direct intervention to increase alveolar ventilation and improve gas exchange. Deep breathing expands the lungs, promotes the recruitment of collapsed alveoli, and increases the amount of oxygen reaching the pulmonary capillaries. This can rapidly help raise the oxygen saturation back toward the normal range of 95 to 100 percent. It is a non-invasive, immediate nursing action that empowers the client to improve their own respiratory status.
Choice D rationale
Requesting a prescription for an opioid analgesic is contraindicated for a client with low oxygen saturation unless the hypoxia is caused by severe pain inhibiting breathing. Opioids are central nervous system depressants that can significantly decrease the respiratory rate and depth of ventilation. Administering an opioid could worsen the client's condition by causing further respiratory depression and lowering the oxygen saturation even more. The priority is to support ventilation and oxygenation, not suppress it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E","F"]
Explanation
Choice A rationale
Assessment is a core part of the nursing process that requires clinical judgment and specialized knowledge. The registered nurse must evaluate the nature, intensity, and location of pain to develop an appropriate plan of care. Unlicensed personnel lack the training to interpret physiological and psychological data. Delegating assessment can lead to missed complications or delayed treatment. Therefore, the nurse remains responsible for all patient assessments.
Choice B rationale
Obtaining vital signs is a routine, technical task that can be safely delegated when the patient is physiologically stable. The assistant must be trained in the procedure and know the parameters to report. The nurse retains responsibility for interpreting these values in the context of the patient's condition. Normal adult vital signs typically include a heart rate of 60 to 100 beats per minute and a respiratory rate of 12 to 20 breaths.
Choice C rationale
Discharge teaching involves complex education regarding medications, activity restrictions, and follow-up care tailored to the patient's specific needs. This task requires the pedagogical skills and clinical expertise of a registered nurse. Unlicensed staff are not qualified to provide formal education or evaluate the patient's readiness for discharge. Effective teaching ensures patient safety and reduces readmission rates. The nurse must document the patient's understanding and any barriers to learning encountered during the session.
Choice D rationale
Dressing changes for surgical or complex wounds often require sterile technique and the ability to assess wound healing or signs of infection. These tasks are generally outside the scope of unlicensed personnel unless the wound is simple and chronic. The nurse must inspect the site for redness, edema, or purulent drainage. Improper technique by untrained staff can introduce pathogens, leading to sepsis or delayed recovery. Clinical judgment is necessary during the procedure.
Choice E rationale
Assisting with activities of daily living is a fundamental role of unlicensed personnel. This includes helping patients with bathing, dressing, and feeding to meet self-care deficits. These tasks are repetitive and do not require the complex clinical judgment of a licensed professional. By delegating these duties, the nurse can focus on higher-level clinical interventions. However, the nurse must still supervise and ensure the patient's safety and comfort are maintained during these activities.
Choice F rationale
Phlebotomy is a technical skill that many facilities allow trained unlicensed personnel to perform once they have demonstrated competency. This involves the collection of blood samples for laboratory analysis while maintaining aseptic technique. While it requires precision, it does not involve the diagnostic assessment or clinical reasoning reserved for the nurse. The nurse must ensure the samples are labeled correctly and sent to the lab promptly. Success depends on following strict facility protocols.
Correct Answer is C
Explanation
Choice A rationale
The brachial pulse is located in the antecubital fossa and is primarily used for blood pressure measurement or assessing circulation in the infant. While it reflects systemic arterial pressure, it is not the standard peripheral site used for calculating a pulse deficit in adults. A pulse deficit occurs when the heart's contractions are too weak to transmit a palpable pressure wave to the periphery, and the radial artery is the conventional comparative site.
Choice B rationale
The dorsalis pedis pulse is found on the dorsal aspect of the foot and is used to evaluate peripheral vascular status in the lower extremities. Because of its significant distance from the heart, there is a natural delay and potential for dampened amplitude due to peripheral artery disease. It is not used for pulse deficit assessments because it does not provide a reliable immediate comparison to the central cardiac activity represented by the apical pulse.
Choice C rationale
A pulse deficit is determined by simultaneously measuring the apical pulse via auscultation and the radial pulse via palpation for one full minute. The radial artery is the most distal easily accessible site that should normally reflect every ventricular contraction. A difference between the apical and radial rates indicates that some cardiac contractions are not producing enough stroke volume to be felt peripherally, often seen in conditions like atrial fibrillation.
Choice D rationale
The carotid pulse is a central pulse located in the neck, reflecting pressure changes very close to the aorta. Because of its proximity to the heart, it is less likely to show a deficit compared to more distal peripheral sites. Using the carotid pulse would not accurately identify a pulse deficit because it usually remains palpable even when stroke volume is diminished, whereas the radial pulse would disappear, highlighting the discrepancy in perfusion.
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