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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Complete blood count: Primarily measures the number of blood cells and their types. It does not directly assess the effectiveness of warfarin.
B. Creatinine clearance: Evaluates kidney function and doesn't directly reflect the efficacy of warfarin.
C. Prothrombin time (PT): Measures the time taken for blood to clot, an essential indicator for monitoring anticoagulation therapy like warfarin.
D. Serum troponin levels: Assesses cardiac damage and is not indicative of warfarin's effectiveness in managing atrial fibrillation.
Correct Answer is B
Explanation
A. Asking about the bowel sterilization prescription isn't directly related to the client's concern about the visibility of the surgical opening.
B. Reviewing the client's expectations regarding elimination after surgery helps address the client's concerns about the surgical opening and ensures proper education and understanding.
C. Verifying the NPO status is important for surgery preparation but doesn’t address the client's specific concern.
D. Understanding if this is the client's first indwelling catheter doesn’t directly address the immediate concern of the client regarding the visibility of the surgical opening.
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