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 C
Explanation
Choice A reason: Serosanguineous drainage is a mixture of blood and clear fluid, not typically yellow and thick.
Choice B reason: Serous drainage is clear and watery, not yellow and thick.
Choice C reason: Purulent drainage is typically yellow and thick, indicating the presence of pus, which can be a sign of infection.
Choice D reason: Sanguineous drainage is fresh bleeding, bright red in color, not yellow and thick.
Correct Answer is D
Explanation
Choice A reason: While nurses play a role in the informed consent process, they are not responsible for obtaining the consent for the surgery.
Choice B reason: An anesthesiologist may obtain consent for anesthesia but not for the surgical procedure itself.
Choice C reason: The surgical suite nurse assists in the operating room but does not obtain consent for the surgery.
Choice D reason: The surgeon performing the procedure is responsible for obtaining informed consent from the patient, making this the correct answer.
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