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 B

Explanation

Choice A rationale
It is a good practice to change the batteries in smoke detectors annually to ensure they are working properly. This statement does not indicate a need for further instruction.
Choice B rationale
Using a walker when going upstairs can be dangerous due to the risk of falls. It is recommended that individuals use handrails or assistance when navigating stairs, not a walker. This statement indicates that the client needs further instruction.
Choice C rationale
Leaving a night light on can help prevent falls by providing visibility during the night. This statement does not indicate a need for further instruction.
Choice D rationale

Installing grab bars in the bathroom, especially near the toilet and in the shower, can provide support and prevent falls. This statement does not indicate a need for further instruction.

Correct Answer is ["2 ."]

Explanation

Step 1: Identify the prescribed dose and the available dose. The prescribed dose is 500 mg and the available dose is 250 mg per tablet.

Step 2: Use the formula for calculating the number of tablets: (Prescribed dose ÷ Available dose) = Number of tablets.
Step 3: Substitute the values into the formula: (500 mg ÷ 250 mg/tablet) = 2 tablets. So, the nurse should administer 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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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?