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 A
Explanation
A. "May I sit with you for a while?" - This response offers companionship and emotional support without pushing the resident to engage in an activity or prying into his feelings. It respects his desire for solitude while providing the option for company if he wishes.
B. "Why do you want to stay in your room today?" - This might be perceived as intrusive and pushy, potentially making the resident more withdrawn.
C. "Come into the recreation area. We have your favorite card game and I will play it with you." - While well-intentioned, this suggestion may not align with the resident's current emotional state or desire for solitude.
D. "I know you are sad about not seeing your family as often, but they are visiting as much as they can." - This response acknowledges the resident's feelings but may not address his immediate need for companionship or support.
Correct Answer is A
Explanation
A. Encouraging the client to use the spirometer before analgesia is important as it helps prevent respiratory complications post-surgery. It's crucial for optimal recovery.
B. Rescheduling the spirometer instruction may delay a critical intervention for the client's postoperative care.
C. Providing a PRN analgesic before spirometer use might hinder the client from benefiting fully from the respiratory therapy.
D. Reassuring the client that the incentive spirometer is not painful doesn't address the client's request for analgesia before using it.
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