Patient Data
What is the rationale for the order of supplemental oxygen 10 L/min via nasal cannula? Select the best answer.
To prevent hypoxia and tissue damage due to pneumonia.
To lower the blood pressure and reduce the workload of the heart.
To increase the oxygen saturation and improve the respiratory function.
To dilate the bronchioles and decrease the inflammation of the lungs.
The Correct Answer is A
Choice A rationale:
Supplemental oxygen is given to the patient to prevent hypoxia and tissue damage due to pneumonia. Pneumonia is an infection that inflames the air sacs in one or both lungs, which may fill with fluid or pus, causing cough with phlegm or pus, fever, chills, and difficulty breathing. Hypoxia occurs when the body or a region of the body is deprived of adequate oxygen supply at the tissue level. It can cause serious damage to your heart, brain, and other organs. Hence, supplemental oxygen is administered to ensure that the patient’s tissues receive adequate oxygen.
Choice B rationale:
While supplemental oxygen can indirectly help lower blood pressure by improving oxygen supply and reducing strain on the heart, it is not primarily used for this purpose. Enalapril, which the patient is already taking, is an angiotensin-converting enzyme (ACE) inhibitor that is commonly used to lower blood pressure and reduce the workload of the heart.
Choice C rationale:
Supplemental oxygen does increase the oxygen saturation and improve respiratory function. However, this is a more general rationale for providing supplemental oxygen and not specific to this patient’s condition of pneumonia.
Choice D rationale:
Supplemental oxygen does not directly dilate the bronchioles or decrease inflammation in the lungs. Medications such as bronchodilators and corticosteroids are typically used for these purposes. In this case, supplemental oxygen is being used to prevent hypoxia and tissue damage due to pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the correct answer because BUN and creatinine are the most important laboratory values to monitor for nephrotoxicity, which is the damage or injury to the kidneys caused by certain drugs or chemicals.
Nephrotoxicity can impair the kidneys' ability to filter waste products from the blood, resulting in elevated levels of BUN and creatinine. The normal range for BUN is 7 to 20 mg/dL, and for creatinine is 0.6 to 1.2 mg/dL. The practical nurse (PN) should review these values before administering an antibiotic that can cause nephrotoxicity, such as aminoglycosides, cephalosporins, vancomycin, or sulfonamides. The PN should also monitor the client for signs and symptoms of nephrotoxicity, such as decreased urine output, edema, hypertension, fatigue, nausea, and confusion.
a) Serum calcium
This is not the correct answer because serum calcium is not directly related to nephrotoxicity. Serum calcium is the amount of calcium in the blood, which is important for bone health, muscle contraction, nerve function, and blood clotting. The normal range for serum calcium is 8.5 to 10.2 mg/dL. Serum calcium may be affected by kidney disease, but it is not a reliable indicator of nephrotoxicity.
b) Hemoglobin and hematocrit
This is not the correct answer because hemoglobin and hematocrit are not directly related to nephrotoxicity. Hemoglobin is the protein in red blood cells that carries oxygen, and hematocrit is the percentage of red blood cells in the blood. The normal range for hemoglobin is 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women, and for hematocrit is 38.8 to 50% for men and 34.9 to 44.5% for women.
Hemoglobin and hematocrit may be affected by kidney disease, but they are not reliable indicators of
nephrotoxicity.
c) White blood cell count (WBC)
This is not the correct answer because WBC is not directly related to nephrotoxicity. WBC is the number of white blood cells in the blood, which are part of the immune system and fight infections. The normal range for WBC is 4,500 to 10,000 cells per microliter of blood. WBC may be elevated in response to an infection or inflammation, but it is not a reliable indicator of nephrotoxicity.
Correct Answer is C
Explanation
The correct answer is choice C: Ensure that the call bell is easily accessible to the client.
Choice C rationale: Ensuring that the call bell is easily accessible empowers the client to promptly request assistance if needed during the night. This promotes safety and reduces anxiety, as the client can quickly contact the nurse if they experience an urgent need to use the restroom or require any other assistance during the night.
Choice A rationale: Reassuring the client that someone will check on him hourly may provide some comfort, but it does not directly address the client's issue of urinary frequency. Ensuring easy access to the call bell is a more targeted approach to managing the client's needs.
Choice B rationale: Placing fresh water and a glass within reach on the bedside table is a good practice to maintain hydration, but it does not directly address the client's urinary frequency issue.
Choice D rationale: Offering an evening snack and oral care is essential for the client's overall well-being, but it is not directly related to managing the client's urinary frequency at night. The primary focus should be on ensuring that the client can access assistance quickly when needed.
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