The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?
Switch to a non-rebreather mask.
Remove the nasal cannula.
Increase the oxygen to 3 L/minute.
Verify the placement of the pulse oximeter.
The Correct Answer is D
Choice A reason: Switching to a non-rebreather mask is not the immediate action to take. Non-rebreather masks deliver a high concentration of oxygen, typically reserved for severe hypoxia. The patient’s oxygen saturation is low, but not critically low. It’s important to first ensure the accuracy of the reading before escalating oxygen delivery methods.
Choice B reason: Removing the nasal cannula is not advisable. The patient is postoperative and may have impaired gas exchange due to anesthesia, pain, or decreased mobility. Removing the supplemental oxygen may worsen the patient’s hypoxemia and increase the risk of complications.
Choice C reason: Increasing the oxygen to 3 L/minute could be a potential action if the oxygen saturation reading is accurate and the patient’s condition does not improve. However, any changes to a patient’s oxygen therapy should be made under the guidance of a healthcare provider. It’s important to first verify the accuracy of the oxygen saturation reading.
Choice D reason: Verifying the placement of the pulse oximeter is the highest priority action. Before making changes to the oxygen flow rate, it’s important to ensure that the oxygen saturation reading is accurate. Incorrect placement or function of the pulse oximeter could lead to inaccurate readings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A Reason: This is correct because hospice provides comfort, dignity, and emotional support to clients with terminal illnesses and their families. Hospice focuses on palliative care rather than curative treatment.
Choice B Reason: This is correct because hospice can be provided within comforts of home or in other settings such as nursing homes or hospice facilities. Hospice allows clients to die in their preferred environment.
Choice C Reason: This is correct because hospice services can be initiated prior to discharge from the hospital or at any time during the course of the illness. Hospice requires a physician's order and a prognosis of six months or less to live.
Choice D Reason: This is correct because family members can be involved in the plan of care and receive education, counseling, and bereavement support from hospice staff. Hospice promotes family-centered care and respects cultural and spiritual preferences.
Choice E Reason: This is incorrect because a living will remains valid when receiving hospice care. A living will is a legal document that expresses the client's wishes regarding life-sustaining treatments in case of incapacity.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because a one ounce medicine cup is not precise enough to measure a 5 mL dose of viscous liquid solution. A one ounce medicine cup can hold about 30 mL of liquid, which is too large for a small dose.
Choice B Reason: This is incorrect because a 3 mL syringe and a sterile needle is not appropriate for oral administration of medication. A needle may cause injury to the oral mucosa or the esophagus.
Choice C Reason: This is correct because a 3 mL syringe can measure a 5 mL dose of viscous liquid solution accurately and safely. A syringe can draw up the solution easily and deliver it to the mouth without spilling or dripping.
Choice D Reason: This is incorrect because a tuberculin syringe is too small to measure a 5 mL dose of viscous liquid solution. A tuberculin syringe can hold only 1 mL of liquid, which is not enough for the required dose.
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