The practical nurse (PN) is completing a focused assessment on a client who is prescribed oxygen at 3 liters per minute by nasal cannula. Which assessment finding by the PN requires immediate action?
The flowmeter shows 1 liter of oxygen being delivered
There is no humidifier atached to the delivery system
The client is lying in a supine position in the bed.
The cannula is pressed snugly against the client's cheeks.
The Correct Answer is A
A. This finding requires immediate action, as it indicates that the client is not receiving the prescribed amount of oxygen, which can compromise the oxygenation and perfusion of the tissues. The PN should adjust the flowmeter to deliver 3 liters per minute of oxygen, and check for any leaks or kinks in the tubing.
The other options are not correct because:
B. The absence of a humidifier does not require immediate action, as it is not a critical component of the oxygen delivery system. A humidifier can help moisten the dry oxygen and prevent mucosal irritation, but it is not essential for oxygenation.
CThe supine position does not require immediate action, as it is not a contraindication for oxygen therapy. The client may prefer this position for comfort or rest, and it does not affect the oxygen delivery or uptake.
D . The snug fit of the cannula does not require immediate action, as it is not a problem for oxygen therapy. The cannula should fit snugly against the client's cheeks to prevent dislodgment or slippage, and it does not interfere with the oxygen flow or diffusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. Verify that Client B has two units of packed cells available.
Choice A rationale:
Moving Client D into an isolation room 24 hours before surgery is not necessary solely based on an elevated WBC count. Elevated WBCs indicate infection or inflammation, but isolation is not typically required unless there is a contagious infection.
Choice B rationale:
Client C’s potassium level of 3.8 mEq/L is within the normal range (3.5 to 5.0 mEq/L). Adding a banana, which is high in potassium, is not necessary.
Choice C rationale:
Client A with emphysema and an oxygen saturation of 94% does not require an increase in oxygen. Oxygen therapy should be carefully managed in clients with emphysema to avoid suppressing their respiratory drive.
Choice D rationale:
Client B has a postoperative hemoglobin of 8.2 mg/dL, which is significantly below the normal range (14 to 18 g/dL). This client may require a blood transfusion to address the low hemoglobin level, making it essential to verify the availability of packed red blood cells.
Correct Answer is A
Explanation
To calculate the amount of darbepoetin alfa that the nurse should administer, you can use the following formula:
Dose (mL) = Amount prescribed (mcg) / Concentration (mcg/mL)
In this case:
Amount prescribed = 40 mcg
Concentration = 60 mcg/mL
Dose (mL) = 40 mcg / 60 mcg/mL = 2/3 mL
Now, you can convert 2/3 mL to decimal to make it easier to work with:
2/3 = 0.6667 mL
Rounded to one decimal place, the nurse should administer approximately 0.7 mL of darbepoetin alfa. So, the correct answer is 0.7 mL.
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