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
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Correct Answer is C
Explanation
Choice A reason: Cisapride is a prokinetic agent that increases gastrointestinal motility and is unlikely to cause constipation.
Choice B reason: Magnesium-containing antacids typically cause diarrhea rather than constipation.
Choice C reason: Opioid analgesics are known to slow gastrointestinal motility, which can lead to constipation, making this the correct answer.
Choice D reason: Statins are used to lower cholesterol and are not commonly associated with causing constipation.
Choice E reason: Anticholinergic/antispasmodic medications can cause constipation due to their action on the nervous system, which reduces muscle contractions in the gastrointestinal tract.
Correct Answer is B
Explanation
Choice A reason: Increased length of stay is not a direct outcome of preoperative teaching and depends on many factors.
Choice B reason: Reduced postoperative respiratory function can be a concern, and preoperative teaching aims to mitigate this risk by educating on breathing exercises and mobilization.
Choice C reason: Preoperative teaching should help manage expectations and pain control strategies, not increase postoperative pain.
Choice D reason: Preoperative teaching should aim to reduce anxiety by providing information and reassurance, not induce it.
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