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 B
Explanation
Choice A reason: While bed rest may be required immediately after surgery, patients are typically encouraged to mobilize as soon as possible to prevent complications.
Choice B reason: Using a special soap the evening before surgery is a common preoperative instruction to reduce the risk of infection.
Choice C reason: A CPM machine is often used after hip replacement surgery to promote movement and prevent joint stiffness.
Choice D reason: A heating pad is generally not recommended on the operative site immediately after surgery due to the risk of burns and bleeding.
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The correct answer is choice B. “You will use a special soap to shower with the evening before your surgery.” Choice A rationale: Remaining in bed for at least the first 24 hours is not typically recommended. Early mobilization is encouraged to prevent complications such as blood clots and to promote faster recovery. Choice B rationale: Using a special soap to shower with the evening before surgery is a common preoperative instruction. This helps reduce the risk of infection by decreasing the number of bacteria on the skin. Choice C rationale: Continuous passive motion (CPM) machines are generally used for knee replacement surgeries, not hip replacements. They help in maintaining joint mobility and preventing stiffness, but are not standard for hip surgeries. Choice D rationale: Using a heating pad on the operative site is not recommended as it can increase swelling and the risk of burns. Cold therapy is usually preferred to reduce pain and inflammation postoperatively. |
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Correct Answer is D
Explanation
Choice A reason: While opioids can lower blood pressure, it is not as common as respiratory depression.
Choice B reason: Causing drowsiness is a common side effect of opioids, but it is less critical than respiratory effects.
Choice C reason: Opioids do not typically induce a cough; they may actually suppress coughing.
Choice D reason: Opioids can slow the respiratory rate, which is a critical side effect that nurses must monitor for and educate patients about.
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