RH has a history of COPD. The CNA checks his vital signs at the beginning of the shift and tells you that his pulse ox reading is 91%. What should the nurse advise the CAN does next:

Chart the reading at 91%, this is normal for a COPD patient.

Place a non-rebreather on the patient with high ﬂow oxygen.

Call the doctor if the patient is declining.

Sit the patient up and have them breathe deep.

Answer and Explanation

The Correct Answer is D

Sitting the patient up and encouraging deep breathing can help improve oxygenation and increase the pulse oximetry reading. This is a non-invasive intervention that can be implemented immediately to help improve the patient’s oxygen levels.

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Correct Answer is A

Explanation

The use of an incentive spirometer is essential after surgery to prevent complications such as pneumonia and atelectasis. Atelectasis is the collapse of air sacs in the lungs, which can occur after surgery due to decreased respiratory eﬀort and shallow breathing. An incentive spirometer helps the patient take deep breaths and increase their lung volume, preventing these complications.

Breathing rapidly to prevent pneumonia (option b) is not recommended as it can lead to hyperventilation and other respiratory complications.

Option c is incorrect because patient education is a crucial aspect of post-operative care, and the patient needs to be aware of the potential complications and how to prevent them.

The use of a chest tube (option d) is not usually required after hip surgery, and it is not a priority teaching for the patient.

A. The chest tube drainage system should be placed on the bedside table. B. The chest tube drainage system should be placed on the bed near the patient. C. The chest tube drainage system must be placed below the site of insertion. D. The chest tube drainage system should be placed on the siderail near the patient.

Correct Answer is C

Explanation

: Chest tube placement is done to remove air or ﬂuid from the pleural space, which is the area between the lungs and the chest wall. The chest tube drainage system is an important tool to monitor and manage the drainage from the chest tube.

It is essential that the chest tube drainage system is placed below the level of the patient's chest and the site of insertion. This is necessary to create a continuous drainage system by allowing gravity to assist in the ﬂow of air or ﬂuid out of the pleural space. If the chest tube drainage system is placed above the insertion site, the ﬂuid will not drain properly, which can cause the ﬂuid to back up into the patient's chest cavity, leading to complications such as pneumothorax or hemothorax.

Therefore, the appropriate statement regarding a chest tube is that the chest tube drainage system must be placed below the site of insertion.

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RH has a history of COPD. The CNA checks his vital signs at the beginning of the shift and tells you that his pulse ox reading is 91%. What should the nurse advise the CAN does next:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who recently had surgery on her left hip. What should be the priority teaching for the patient after surgery to prevent complications?

Correct Answer is A

Explanation

The nurse is caring for a client with a chest tube. Which is the following statements is appropriate regarding a chest tube?

Correct Answer is C

Explanation

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RH has a history of COPD. The CNA checks his vital signs at the beginning of the shift and tells you that his pulse ox reading is 91%. What should the nurse advise the CAN does next:

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