The practical nurse (PN) observes a client's mouth and lips as seen in the picture. Which follow-up action is most important for the PN to take?
Ask about pain.
Provide mouth care.
Offer fluids.
Administer oxygen.
The Correct Answer is D
A. Ask about pain. This is not the most important action because pain is not the primary problem in this situation. Pain may or may not be present, but it does not address the underlying cause of cyanosis.
B. Provide mouth care. This is not the most important action because mouth care does not improve oxygenation. Mouth care may be helpful to prevent infection and promote comfort, but it is not a priority in this case.
C. Offer fluids. This is not the most important action because fluids do not increase oxygen levels in the blood. Fluids may be beneficial to prevent dehydration and maintain circulation, but they are not urgent in this scenario.
D. Administer oxygen. This is the most important action because oxygen is essential for cellular function and survival. Oxygen therapy can reverse hypoxia and improve the client's condition.
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Related Questions
Correct Answer is C
Explanation
A. Encouraging the client to use the spirometer before analgesia can increase discomfort and reduce effort, leading to ineffective deep breathing. Pain control should be optimized first to promote participation and proper technique.
B. Delaying instruction for several hours postpones an important postoperative intervention that helps prevent complications such as atelectasis. Early and consistent use of the spirometer is essential for optimal recovery.
C. Administering a PRN analgesic first improves comfort, allowing the client to take deeper breaths and use the spirometer effectively. This approach supports both pain management and respiratory function, making it the best choice.
D. Reassuring the client that the spirometer is not painful dismisses the client’s concern and does not address the need for pain control. Postoperative clients often experience pain with deep breathing, so appropriate analgesia is necessary.
Correct Answer is A
Explanation
A. Determine the means by which residents will be evacuated. - This task requires critical decision-making and understanding of evacuation protocols, which is within the scope of the practical nurse's responsibilities.
B. Close all fire doors and the doors to all the residents' rooms. - While important for containment, this can be executed by UAP following established protocols.
C. Assist any wandering residents back to their rooms. - UAP can assist in guiding residents back to their rooms safely.
D. Offer comfort and reassurance to distraught residents. - Both PN and UAP can offer comfort and reassurance to residents during such situations.
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