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. 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.
Correct Answer is A
Explanation
A. Assessing the client's mental status is crucial before administering zolpidem, a sleep aid, as it helps ensure the client is alert enough to take the medication safely. This assessment includes evaluating the client's level of consciousness, orientation, and cognitive function.
B. Monitoring body temperature might be necessary in certain clinical situations, but it's not directly relevant before administering zolpidem unless there are specific concerns related to body temperature.
C. Assessing bowel sounds is an important part of a comprehensive physical assessment, but it's not directly tied to the administration of a sleep aid like zolpidem.
D. Evaluating skin integrity is important for overall patient care, but it's not specifically linked to the assessment needed before administering a sleep medication like zolpidem.
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