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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Has both older and younger siblings: This does not specifically relate to the "sandwich generation" concept.

B. Cares for children and aging parents at the same time: The term "sandwich generation" refers to individuals who are simultaneously caring for their own children and their aging parents.

C. There is a role reversal between parents and self: While this may occur in caregiving situations, it doesn't define the "sandwich generation."

D. Assists own parents and spouse's parents: This is similar to option B but specifically refers to assisting one's own parents and the spouse's parents, not necessarily at the same time.

A. Ask the client to read a Snellen chart. B. Listen to the client's speech. C. Ask the client to clench his teeth. D. Ask the client to identify scented aromas.

Correct Answer is A

Explanation

A. Ask the client to read a Snellen chart: Cranial nerve II (Optic nerve) is responsible for vision. Assessing the client's ability to read a Snellen chart tests visual acuity, which is a function of cranial nerve II.

B. Listen to the client's speech: This assesses cranial nerves V (Trigeminal) and VII (Facial), which are involved in speech and facial sensation.

C. Ask the client to clench his teeth: This assesses cranial nerve V (Trigeminal), which controls jaw movement and sensation.

D. Ask the client to identify scented aromas: This assesses cranial nerve I (Olfactory), which is responsible for the sense of smell.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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