A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?
Administer oxygen at 2 U/min.
Raise the head of the bed.
Encourage coughing and deep breathing
Administer prescribed analgesic medication
The Correct Answer is B
A. Administer oxygen at 2 L/min: Administering oxygen is important but should be done after positioning the client to improve natural ventilation.
B. Raise the head of the bed: Raising the head of the bed is the first action to take as it facilitates better lung expansion and improves ventilation. This can help increase the oxygen saturation more immediately and effectively.
C. Encourage coughing and deep breathing: Encouraging coughing and deep breathing is also beneficial to help clear secretions and improve lung function, but positioning the client for optimal breathing should be prioritized first.
D. Administer prescribed analgesic medication. Administering analgesics may be necessary for pain management, but it does not directly address the immediate need to improve oxygen saturation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Set client-centered, measurable and realistic goals: This occurs during the planning stage, after data collection and analysis.
B. Critically analyze client data to determine priorities: This step happens after data collection during the diagnosis phase.
C. Determine effectiveness of interventions: This is part of the evaluation stage, which comes after planning and implementation.
D. Collect and organize client data: This is the first step in the nursing process, where the nurse gathers comprehensive information about the client's physical, psychological, sociocultural, developmental, and spiritual needs.
Correct Answer is A
Explanation
A. Bend at the knees when picking up an object: This technique helps distribute the weight of the object and reduces strain on the back muscles.
B. Relax her abdominal muscles when she lifts an object: Tensing the abdominal muscles can provide core support, but relaxing them while lifting can increase the risk of injury.
C. Twist at the waist when she moves an object to one side: Twisting at the waist can strain the back muscles and should be avoided.
D. Hold an object away from her body as she lifts it: Holding objects close to the body reduces strain on the back muscles and is a good technique to prevent injury.
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