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 A
Explanation
The correct answer is choice A. Gather the procedure tray and equipment.
Choice A rationale:
The practical nurse should gather the necessary procedure tray and equipment to ensure everything is ready for the healthcare provider to perform the thoracentesis efficiently and safely.
Choice B rationale:
Cleansing the site and covering it with a sterile towel is part of the procedure itself and should be done by the healthcare provider performing the thoracentesis.
Choice C rationale:
Keeping the patient NPO (nothing by mouth) and encouraging them to void is not necessary for a thoracentesis. This procedure typically does not require the patient to be NPO.
Choice D rationale:
Placing the patient in an orthopneic position (sitting up and leaning forward) is important for the procedure, but it should be done closer to the time of the procedure, not necessarily as a preparatory step.
Correct Answer is B
Explanation
Choice A rationale:
Choice B rationale:
Choice C rationale:
Severe motor dysfunction determines the extent of successful habilitation is not entirely accurate. While the severity of motor dysfunction does play a role in the challenges a child with CP may face, it does not solely determine the extent of successful habilitation. Many factors, including early intervention, therapy, and individualized care, can influence a child's progress and potential for improvement.
Choice D rationale:
Continued development of the brain lesion determines the child's outcome is not an accurate statement. CP is primarily caused by non-pro
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