Monocytes differentiate into large phagocytic cells. True or False?

Choice A rationale

Decreasing the head of the bed or placing the client in a supine position can negatively impact respiratory effort by allowing abdominal organs to push against the diaphragm. This reduces lung expansion and can further lower oxygen saturation from 88 percent. For a client with low oxygen levels, the nurse should instead elevate the head of the bed to a semi-Fowler's or high-Fowler's position. This maximizes thoracic cavity space and improves the efficiency of gas exchange.

Choice B rationale

Asking the client to cough every 4 hours is an infrequent intervention that may not be sufficient to address an acute oxygen saturation of 88 percent. While coughing helps clear secretions, a four-hour interval is too long for a client currently experiencing significant desaturation. Immediate nursing actions should focus on improving current ventilation and oxygenation. Coughing and deep breathing are more effective when performed more frequently, such as every hour while awake, to prevent atelectasis.

Choice C rationale

Encouraging the client to take deep breaths is a direct intervention to increase alveolar ventilation and improve gas exchange. Deep breathing expands the lungs, promotes the recruitment of collapsed alveoli, and increases the amount of oxygen reaching the pulmonary capillaries. This can rapidly help raise the oxygen saturation back toward the normal range of 95 to 100 percent. It is a non-invasive, immediate nursing action that empowers the client to improve their own respiratory status.

Choice D rationale

Requesting a prescription for an opioid analgesic is contraindicated for a client with low oxygen saturation unless the hypoxia is caused by severe pain inhibiting breathing. Opioids are central nervous system depressants that can significantly decrease the respiratory rate and depth of ventilation. Administering an opioid could worsen the client's condition by causing further respiratory depression and lowering the oxygen saturation even more. The priority is to support ventilation and oxygenation, not suppress it.

Choice A rationale

The reported pulse rate of 92 beats per minute falls within the expected reference range for a healthy adult, which is typically between 60 and 100 beats per minute. Because this value is hemodynamically stable and normal, there is no immediate physiological indication that the nurse needs to re-measure it. The AP's finding is consistent with a resting state, and unless the patient is symptomatic or has a specific cardiac history, this measurement is accepted.

Choice B rationale

The respiratory rate of 18 breaths per minute is within the normal adult range of 12 to 20 breaths per minute. This finding indicates that the patient is likely ventilating adequately without acute distress. Since the value is not tachypneic or bradypneic, re-measurement is not a priority. The nurse should continue to observe the patient's work of breathing and oxygen saturation, but the reported rate itself does not necessitate an immediate verification by the licensed nurse.

Choice C rationale

The reported blood pressure of 98/58 mm Hg is considered low, as a typical normal reading is approximately 120/80 mm Hg. Hypotension, generally defined as a systolic pressure below 90 mm Hg or a significantly low diastolic pressure, requires professional verification to ensure patient safety and clinical accuracy. The nurse must assess for signs of decreased organ perfusion, such as dizziness or confusion, and confirm the reading before making interventions or notifying the provider about the status.

Choice D rationale

A temperature of 98.8 F is well within the normal afebrile range for an adult, which usually spans from 96.4 F to 99.1 F. Since this reading does not indicate a fever or hypothermia, there is no clinical reason to doubt the AP's measurement or to perform a repeat assessment. The patient’s thermoregulation appears intact, and the nurse can move on to addressing more concerning vital signs, such as the low blood pressure reported in the set.