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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: 1 tablet provides 0.2 mg, less than the ordered 0.3 mg. This underdoses the patient, failing to control postpartum bleeding effectively, making 1 tablet incorrect for the prescribed dose.

Choice B reason: Methergine 0.3 mg divided by 0.2 mg/tablet equals 1.5 tablets (0.3 ÷ 0.2 = 1.5). This delivers the exact dose, and 1.5 is already rounded to the nearest tenth, making it correct.

Choice C reason: 2 tablets provide 0.4 mg, exceeding the 0.3 mg order. This overdose risks side effects like hypertension, making 2 tablets incorrect for the prescribed dosage.

Choice D reason: 2.5 tablets deliver 0.5 mg, significantly exceeding the 0.3 mg order. This overdose increases adverse effects, making 2.5 tablets incorrect for the correct dosage administration.

A. Low blood pressure B. Cancer C. Diabetes D. Alkalosis E. Infections

Correct Answer is ["C","E"]

Explanation

Choice A reason: Prolonged stress elevates cortisol, increasing blood pressure via vasoconstriction and sodium retention, not lowering it. Low blood pressure is not a typical stress-related condition, making this an incorrect choice for monitoring.

Choice B reason: Cancer risk may increase with chronic stress due to immune suppression, but it is not an immediate condition to monitor. Acute stress-related issues like diabetes or infections are more urgent, making this incorrect.

Choice C reason: Prolonged stress increases cortisol, promoting insulin resistance and hyperglycemia, raising diabetes risk. Monitoring blood glucose is critical, as stress exacerbates glycemic control, making this a correct condition to monitor.

Choice D reason: Alkalosis is not directly linked to prolonged stress, which more commonly causes metabolic acidosis in severe cases (e.g., lactic acidosis). Respiratory or metabolic alkalosis is less relevant, making this incorrect.

Choice E reason: Prolonged stress suppresses immunity via cortisol, increasing infection susceptibility. Monitoring for signs like fever or delayed healing is essential, as infections are a common stress complication, making this correct.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The physician orders Methergine 0.3 mg by mouth twice a day for postpartum bleeding. The medication is supplied in 0.2-mg tablets. How many tablets will the nurse administer per dose? Round to the nearest tenth.

Correct Answer is B

Explanation

A nurse is assessing a patient with prolonged stress. Which conditions will the nurse monitor for in this patient? (Select all that apply)

Correct Answer is ["C","E"]

Explanation

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