A nurse is caring for a client who has pneumonia.
The client’s oxygen saturation is 85%. What is the first action the nurse should take?

Increase the client’s oral fluid intake.

Initiate humidification therapy.

Raise the head of the bed.

Encourage the client to cough and deep breath.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Increasing the client’s oral fluid intake is not the immediate action the nurse should take. While hydration is important, it does not directly address the client’s low oxygen saturation.
Choice B rationale
Initiating humidification therapy can help to thin secretions and improve oxygenation, but it is not the immediate action the nurse should take.
Choice C rationale
Raising the head of the bed is the first action the nurse should take. This position can help to improve lung expansion and oxygenation.
Choice D rationale
Encouraging the client to cough and deep breath can help to clear secretions and improve oxygenation, but it is not the immediate action the nurse should take.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Step 1 is to determine how many tablets to administer. The client needs 650 mg of aspirin and each tablet contains 325 mg. So, the calculation is 650 mg ÷ 325 mg/tablet.
Step 2 is to perform the calculation. The result is 2 tablets.

A. Request a prescription for the insertion of an indwelling urinary catheter. B. Apply a moisture barrier ointment to the skin. C. Clean the skin and perineum with hot water after each episode of incontinence. D. Check the client’s skin every 8 hours for signs of breakdown. E. Check the client’s skin every 8 hours for signs of breakdown.

Correct Answer is B

Explanation

Choice A rationale
Requesting a prescription for the insertion of an indwelling urinary catheter is not the best option to prevent skin breakdown in a client with urinary incontinence. Catheters can increase the risk of urinary tract infections and should be used as a last resort.
Choice B rationale

Applying a moisture barrier ointment to the skin can help protect the skin from the damaging effects of urine. This can help prevent skin breakdown and is a common practice in the care of clients with urinary incontinence.
Choice C rationale
Cleaning the skin and perineum with hot water after each episode of incontinence is not recommended. Hot water can dry out the skin and cause irritation. It’s better to use warm water and a gentle cleanser.
Choice D rationale
Checking the client’s skin every 8 hours for signs of breakdown is important, but it’s not the only action the nurse should take. The nurse should also take proactive measures to protect the skin, such as applying a moisture barrier ointment.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has pneumonia. The client’s oxygen saturation is 85%. What is the first action the nurse should take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer aspirin 650 mg PO. The available medication is aspirin 325 mg tablets. How many tablets should the nurse administer?

Correct Answer is B

Explanation

A nurse is caring for a client with urinary incontinence. What action should the nurse take to prevent skin breakdown?

Correct Answer is B

Explanation

A nurse is caring for a patient with pneumonia who has been on oxygen therapy for several days. Which of the following symptoms should the nurse recognize as a potential adverse effect of oxygen therapy?

A nurse is preparing to administer amoxicillin 500 mg PO. Available is amoxicillin 250 mg tablets. How many tablets should the nurse administer?

A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing.What is the nurse’s priority action?

A nurse is performing wound care for an older adult patient who has a stage I pressure ulcer. Which of the following types of dressings should the nurse apply to the wound?

Upon inspecting a client’s skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which statement best describes a stage 3 pressure ulcer?

A nurse is discussing with a patient who has reported acute lower back pain after lifting heavy boxes. What information should the nurse emphasize?

A nurse has delegated the application of wrist restraints to an assistive personnel (AP) for a confused patient. The AP has padded the wrist restraints and secured the straps to the bed frame with a double knot. What action should the nurse take?

A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. What action should the nurse take?

A nurse is caring for a client who has pneumonia.
The client’s oxygen saturation is 85%. What is the first action the nurse should take?