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A nurse is caring for a client who has returned to the unit on a stretcher following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

Administer prescribed analgesic medication

Administer oxygen at 2 L/min.

Raise the head of the bed.

Encourage coughing and deep breathing

Answer and Explanation

The Correct Answer is C

A. Administering analgesics is not a priority in managing low oxygen saturation.

B. Administering oxygen is important but should follow positioning to improve oxygenation.

C. Raising the head of the bed improves lung expansion and is the priority intervention.

D. Coughing and deep breathing can follow after oxygenation is stabilized.

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Correct Answer is ["B","D","E"]

Explanation

A. WBC results: The scenario does not mention abnormal WBC results or signs of infection, so this is not relevant to surgical risk in this case.

B. Aspirin: Aspirin has antiplatelet effects and increases the risk of bleeding during and after surgery. This risk is compounded in procedures requiring significant tissue manipulation.

C. Glucose level: No specific glucose value is provided; without evidence of uncontrolled hyperglycemia or hypoglycemia, this is not a confirmed risk factor here.

D. Smoking history: A 20-year history of smoking increases the risk of poor oxygenation, impaired wound healing, and respiratory complications during and after surgery.

E. Type 2 diabetes mellitus: Diabetes increases the risk of delayed wound healing and postoperative infections due to hyperglycemia and impaired immune function.

A. Assisting the client to remove the jewelry. B. Providing education to the client about the surgical procedure. C. Instruct the client on how to use an incentive spirometer. D. Being a witness to informed consent

Correct Answer is A

Explanation

A. Assisting the client to remove jewelry is within the UAP's scope of practice and does not require clinical judgment.

B. Providing education about a surgical procedure requires nursing knowledge and cannot be delegated.

C. Instructing the client on the use of an incentive spirometer is a teaching activity requiring an RN’s expertise.

D. Witnessing informed consent is a legal responsibility that must be performed by an RN.

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A nurse is caring for a client who has returned to the unit on a stretcher following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

Nursing Test Bank

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A nurse is caring for a client who has returned to the unit on a stretcher following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?