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 C
Explanation
A. Assess her feelings about therapeutic abortions in the event the infant has been affected. - While important to consider potential outcomes, immediate care involves preventing transmission and managing the current outbreak.
B. Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary. - Contact tracing is important but not the highest priority in managing the current outbreak.
C. Instruct her to avoid sexual intercourse while active, visible lesions are present. - This is crucial to prevent transmission of the herpes virus to the sexual partner and to reduce the risk of complications for the pregnancy.
D. Determine if the client has taken acyclovir for this outbreak of genital herpes. - While important for understanding the treatment history, instructing the client on preventive measures has a higher priority.
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