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.

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Correct Answer is C

Explanation

Choice A rationale
Slough, which is a layer of yellowish, dead tissue that can develop on the surface of a wound, is not a defining characteristic of a stage 3 pressure ulcer.
Choice B rationale
Persistent reddening of the skin is typically associated with a stage 1 pressure ulcer, not a stage 3. In a stage 1 pressure ulcer, the skin remains intact but may be red and may not blanch (lose color briefly) when you press your finger on it.
Choice C rationale
A stage 3 pressure ulcer involves full-thickness skin loss that appears as a deep crater. The ulcer may extend into the subcutaneous tissue layer, but not through it to the underlying

muscle or bone. This description matches the statement in Choice C, making it the correct answer.
Choice D rationale
A fluid-filled area under the skin could potentially indicate a blister or a stage 2 pressure ulcer, not a stage 3. In a stage 2 pressure ulcer, the outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) are damaged or lost.

A. 1 tablet B. 2 tablets C. 3 tablets D. 4 tablets

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.

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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?

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

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

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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?