The patient complaints of dyspnea and the nurse is concerned the patient may need oxygen. What assessment will the nurse perform to determine if the patient needs supplemental oxygen?
Auscultate breath sounds.
Observe chest expansion
Measure capillary refill
Measure oxygen saturation
The Correct Answer is D
A. Auscultating breath sounds can provide valuable information about the presence of wheezing, crackles, or diminished breath sounds, which may indicate respiratory issues. However, while this assessment is important for understanding the underlying cause of dyspnea, it does not directly measure the patient's oxygenation status.
B. Observing chest expansion can help the nurse assess the mechanics of breathing and whether there are any restrictions in lung expansion. While this assessment is useful, it does not provide a clear indication of the patient's oxygen saturation levels or immediate need for supplemental oxygen.
C. Measuring capillary refill can give insights into peripheral perfusion and circulation, which can be affected by oxygenation. However, it is not the most direct or specific assessment for determining the need for supplemental oxygen in a patient with dyspnea.
D. Measuring oxygen saturation (using a pulse oximeter) provides a direct and objective assessment of the patient's oxygenation status. Normal oxygen saturation levels typically range from 95% to 100%. If the oxygen saturation is below the acceptable range (usually less than 92% in many clinical settings), this would indicate the need for supplemental oxygen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Apnea refers to a temporary cessation of breathing. If a patient is experiencing apnea, there would be a complete stop in respiratory activity, which does not apply to a respiratory rate of 36 breaths per minute.
B. Tachypnea is defined as an increased respiratory rate, typically greater than 20 breaths per minute in adults. A respiratory rate of 36 breaths per minute falls well within this range, indicating that the patient is experiencing tachypnea.
C. Bradypnea refers to a decreased respiratory rate, usually defined as fewer than 12 breaths per minute. Since the patient’s rate is 36 breaths per minute, this option does not apply.
D. Orthopnea refers to difficulty breathing when lying flat and is not specifically related to the respiratory rate itself. It usually describes a positional dyspnea rather than a numerical measurement of breathing.
Correct Answer is ["5.3"]
Explanation
1 kilogram equals 2.2 pounds.
The preschooler weighs 29 pounds, which is approximately 13.18 kilograms (29/2.2). The order is for 40 mg/kg/day
13.18 kg * 40 mg/kg = 527.2 mg/day.
Since the medication is to be administered every 12 hours, divide this daily dosage by 2 to get the per dose amount: 527.2 mg/day / 2 = 263.6 mg/dose.
Now, using the concentration of the elixir, which is 250 mg/5 mL, set up a proportion to find out how many milliliters are needed for the prescribed dose: 250 mg : 5 mL = 263.6 mg : X mL.
Solving for X gives us (263.6 mg * 5 mL) / 250 mg = 5.272 mL per dose.
Rounding to the nearest tenth, the nurse should administer 5.3 mL per dose.
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