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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Do you smoke?" This is a closed-ended question that can be answered with a simple "yes" or "no." It doesn't encourage elaboration or detailed responses.
B. "How are you feeling?" This is an open-ended question that encourages the client to provide more detailed and descriptive responses about their current state or feelings. It allows the client to share more information and gives the nurse a better understanding of their condition.
C. "Are you feeling well?" Similar to option A, this is a closed-ended question. It prompts a "yes" or "no" answer without inviting further discussion or detailed explanation.
D. "Do you use any illicit drugs?" This is another closed-ended question that requires a "yes" or "no" answer. It does not provide the opportunity for the client to discuss their drug use in detail.
Correct Answer is D
Explanation
A. Testing visual acuity: This assesses cranial nerve II (Optic nerve).
B. Observing for facial symmetry: This assesses cranial nerve VII (Facial nerve).
C. Eliciting the gag reflex: This assesses cranial nerves IX and X (Glossopharyngeal and Vagus nerves).
D. Checking the pupillary response to light: This assesses cranial nerve III (Oculomotor nerve), which controls pupil constriction and eye movements.
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