A nurse is planning care for a client who has returned to the unit following a surgical procedure. The client’s oxygen saturation is 88%. Which of the following actions should the nurse take first?
Encourage coughing and deep breathing
Raise the head of the bed
Administer oxygen at 2 L/min
Administer prescribed analgesic medication
The Correct Answer is C
Choice A reason: Coughing and deep breathing improve lung expansion but are less urgent than addressing hypoxemia (88% saturation). Oxygen administration corrects low oxygen levels immediately, making this a secondary action.
Choice B reason: Raising the head of the bed aids breathing by reducing diaphragm pressure, but it does not directly correct hypoxemia. Administering oxygen is the priority to restore saturation, making this less immediate.
Choice C reason: Administering oxygen at 2 L/min is the first action, as 88% saturation indicates hypoxemia, risking organ damage. Oxygen delivery corrects low levels, stabilizing the patient, making this the priority intervention.
Choice D reason: Administering analgesics addresses pain but does not correct hypoxemia. Pain management is secondary to ensuring adequate oxygenation, as low saturation is life-threatening, making this incorrect as the first action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A history of myocardial infarction is not a contraindication for warfarin, often used to prevent thromboembolism in such patients. It requires monitoring, but this is not a barrier, making it incorrect.
Choice B reason: Current peptic ulcer disease is a contraindication for warfarin, as anticoagulation increases bleeding risk in active ulcers. This can lead to life-threatening hemorrhage, making it the correct finding to identify.
Choice C reason: Hypertension is a caution, not a contraindication, for warfarin. Controlled blood pressure allows safe use, with monitoring for bleeding risk, making this incorrect as a contraindication.
Choice D reason: Type 2 diabetes mellitus does not contraindicate warfarin. It requires glycemic control to avoid complications, but diabetes itself is not a barrier, making this incorrect.
Correct Answer is D
Explanation
Choice A reason: Imagery involves visualizing specific scenes or outcomes to reduce stress, not focusing on physical sensations like breathing or muscle relaxation. The group’s focus on body awareness and sequential relaxation aligns with progressive relaxation, making this an incorrect description.
Choice B reason: Meditation typically involves mindfulness or mental focus, not systematic physical relaxation of body parts. The group’s structured progression through breathing and muscle groups is specific to progressive relaxation training, making meditation an incorrect term.
Choice C reason: Group biofeedback uses devices to monitor physiological signals (e.g., heart rate), not verbal guidance to focus on relaxation. The described activity relies on mental focus without equipment, aligning with progressive relaxation, making biofeedback incorrect.
Choice D reason: Progressive relaxation training involves systematically tensing and relaxing muscle groups while focusing on sensations, as described (e.g., breathing, left arm). This technique reduces stress and promotes relaxation, making it the correct description of the group’s activity.
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