A nurse is caring for a patient who has pneumonia. The patient's oxygen saturation is 85%. Which of the following actions should the nurse take first?
Increase the patient's oral fluid intake.
Raise the head of the bed.
Initiate humidified oxygen therapy.
Encourage the patient to cough and deep breathe.
The Correct Answer is B
The correct answer is choice B. Raise the head of the bed.
Choice A rationale:
Increasing the patient’s oral fluid intake is important for hydration and thinning secretions, but it is not the immediate priority when oxygen saturation is critically low.
Choice B rationale:
Raising the head of the bed helps improve lung expansion and facilitates easier breathing, which can quickly improve oxygen saturation levels. This is a critical first step in managing low oxygen saturation.
Choice C rationale:
Initiating humidified oxygen therapy is essential for improving oxygenation, but it should follow the immediate action of raising the head of the bed to optimize breathing.
Choice D rationale:
Encouraging the patient to cough and deep breathe is beneficial for clearing secretions and improving lung function, but it is not the first action to take when oxygen saturation is critically low.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect; patients have the right to refuse treatment at any time, even after signing the consent form.
Choice B reason: While the charge nurse may review the risks, it is typically the responsibility of the provider performing the procedure to ensure the patient understands the risks involved.
Choice C reason: A witness may be required to sign the consent form, but it does not necessarily have to be the patient's partner.
Choice D reason: It is important for the provider to discuss all treatment options with the patient, so they can make an informed decision.
Correct Answer is B
Explanation
Choice A reason: Administering sodium bicarbonate is not indicated for respiratory alkalosis as it is an alkalinizing agent and could worsen the condition.
Choice B reason: Breathing into a paper bag can help to rebreathe CO2, which can help correct the pH in cases of hyperventilation-induced respiratory alkalosis.
Choice C reason: Having the patient's head between their knees is not a standard intervention for respiratory alkalosis and could be uncomfortable or unsafe for the patient.
Choice D reason: Acetazolamide is a diuretic that can cause metabolic acidosis to compensate for respiratory alkalosis, but it is not typically used for acute management of hyperventilation.
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