The nurse receives a new prescription to administer oxygen at 3 L/minute via nasal cannula to maintain an oxygen saturation between 90 and 100% for a client. The nurse obtains an oxygen saturation reading of 85%, and after repositioning the oximeter on a different finger, obtains a second reading of 87%. Which action should the nurse take next?

Place the client in a Trendelenburg position.

Securely place the prongs of the cannula in the nostrils.

Place the pulse oximeter on the client's earlobe.

Document the second reading in the client's record.

Answer and Explanation

The Correct Answer is B

Choice A reason: The Trendelenburg position is not indicated for increasing oxygen saturation and could be harmful, especially for clients with respiratory distress.

Choice B reason: Ensuring that the prongs of the nasal cannula are securely placed in the nostrils is important for effective oxygen delivery, especially if the oxygen saturation remains below the prescribed range.

Choice C reason: Placing the pulse oximeter on the client's earlobe is an alternative site for obtaining a saturation reading, but it does not address the issue of potentially inadequate oxygen delivery.

Choice D reason: While documentation is important, the nurse must first address the low oxygen saturation levels before documenting the readings.

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Correct Answer is A

Explanation

Choice A reason: The results are within the normal reference range for both potassium and sodium, which is expected unless the client's condition has led to significant electrolyte imbalances.

Choice B reason: A serum potassium level of 4.5 mEq/L is at the higher end of the normal range, which might not be expected in a client with vomiting and diarrhea, conditions that often lead to lower potassium levels.

Choice C reason: A serum potassium level of 5.0 mEq/L is at the upper limit of the normal range and could indicate hyperkalemia, especially in the context of severe dehydration.

Choice D reason: A serum sodium level of 149 mEq/L is slightly above the normal range and could indicate hypernatremia, which may occur in dehydration but would require further assessment and intervention.

A. Exercise in the evening. B. Watch television in bed to fall asleep. C. Take an analgesic before bed. D. Avoid alcohol in the evening. E. Try to go to bed and awaken at the same time every day. F. Avoid naps. G. Eat a heavy meal before bed.

Correct Answer is ["D","E","F"]

Explanation

Choice A reason:
Exercising in the evening can actually be counterproductive for some people when it comes to sleep. While regular exercise is beneficial for overall health and can contribute to better sleep, doing it too close to bedtime can stimulate the body, making it harder to relax and fall asleep.

Choice B reason:
Watching television in bed is generally not recommended as part of good sleep hygiene. The light from the screen can interfere with the body's production of melatonin, the hormone that signals it's time to sleep, and engaging content can keep the brain alert rather than allowing it to wind down.

Choice C reason:
Taking an analgesic before bed is not a general recommendation for better sleep unless pain is a specific issue that is preventing sleep. It's important to address the root cause of insomnia rather than masking symptoms with medication.

Choice D reason:
Avoiding alcohol in the evening is a good practice for better sleep. Alcohol can disrupt the sleep cycle and lead to fragmented sleep, even though it may initially seem to help with falling asleep.

Choice E reason:
Going to bed and waking up at the same time every day helps to regulate the body's internal clock, or circadian rhythm, which can improve sleep quality. Consistency is key for this practice to be effective.

Choice F reason:
Avoiding naps, especially in the late afternoon or evening, can help ensure that you are sufficiently tired at bedtime. Napping can interfere with nighttime sleep if done too late in the day or for too long.

Choice G reason:
Eating a heavy meal before bed can lead to discomfort and indigestion, which can make it harder to fall asleep. It's best to have a light snack if needed and avoid large meals close to bedtime.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Exhibits What other recommendations could the nurse give to help the patient have better sleep? Select all that apply.

Correct Answer is ["D","E","F"]

Explanation

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?

The mother of a child born with Tetralogy of Fallot asks the nurse, "Why did this happen to my baby? What did I do wrong?" Which response by the nurse is most helpful?

The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client reports the permit should include another lipoma on the right leg. Which action should the nurse implement?

The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement? Select all that apply.