A nurse is preparing to administer oxygen therapy to a patient who has just undergone abdominal surgery. Which of the following interventions is most important to ensure proper oxygenation?

Encourage the patient to take deep breaths and use an incentive spirometer regularly.

Set the oxygen flow rate based on the patient's subjective feeling of breathlessness.

Administer oxygen at 6 L/min through a nasal cannula without an order.

Place the patient in a Trendelenburg position to facilitate oxygen delivery.

Answer and Explanation

The Correct Answer is A

A.   Encouraging deep breaths and using an incentive spirometer can help prevent atelectasis and improve oxygenation after surgery, as it encourages lung expansion.
B.   Setting the oxygen flow rate based on subjective breathlessness is not ideal; oxygen should be administered according to established protocols and patient need.
C.   Administering oxygen without an order is not appropriate and could lead to oxygen toxicity.
D.   The Trendelenburg position is not necessary for oxygenation and could lead to increased pressure on the abdomen and respiratory distress.

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Correct Answer is B

Explanation

A. Decreased blood pressure is not typically associated with contrast-induced nephropathy. In fact, patients may present with normal or elevated blood pressure, especially in those with a history of chronic hypertension.
B. Metabolic acidosis is a common complication of acute kidney injury (AKI), including contrast-induced nephropathy. As kidney function declines, the kidneys' ability to excrete acids diminishes, leading to the accumulation of acids in the blood and resulting in metabolic acidosis.
C. Hypocalcemia is not a common feature of contrast-induced nephropathy. While AKI can cause disturbances in calcium and phosphate balance, hypocalcemia is not typically a predominant finding.
D. Increased urine specific gravity may not be a significant finding in contrast-induced nephropathy. This condition generally leads to impaired kidney function, which may present with urine output changes, but urine specific gravity can vary depending on the stage of AKI.

A. Administer the feeding solution directly from the refrigerator. B. Flush the tube with 10 mL of cold water C. Position the patient supine at 30 degrees. D. Verify the pH of gastric aspirate is less than 5.0.

Correct Answer is D

Explanation

A. Administering feeding solution directly from the refrigerator can cause discomfort to the patient and increase the risk of gastric upset.
B. Flushing the tube with cold water is not appropriate, as it may irritate the stomach and cause discomfort.
C. Positioning the patient supine at 30 degrees is unsafe, as it increases the risk of aspiration. The patient should be at a higher angle, typically 30-45 degrees.
D. Verifying the pH of gastric aspirate is crucial to ensure the feeding tube is in the correct position and to prevent aspiration of feeding material into the lungs.

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A nurse is preparing to administer oxygen therapy to a patient who has just undergone abdominal surgery. Which of the following interventions is most important to ensure proper oxygenation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

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