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 B
Explanation
A. Acknowledging the general demographics of the disease might indicate understanding but does not explicitly show acceptance of the prognosis.
B. This statement reflects a level of acceptance as the client has found support and comfort from faith and family, indicating a more positive coping mechanism.
C. This statement indicates a sense of disbelief or denial rather than acceptance of the prognosis.
D. Rejecting others' negative statements about the disease doesn’t necessarily indicate acceptance of one's prognosis; it may reflect resistance or denial.
Correct Answer is B
Explanation
A. Encourage the client to resume normal activities after medication administration. - This action could exacerbate the injury and pain and isn't appropriate after pain medication for a fracture.
B. Implement ongoing assessments for signs of shallow or slow breathing. - Hydrocodone, an opioid, can cause respiratory depression. Regular monitoring for respiratory changes is crucial.
C. Observe the client for involuntary movements of the lips and tongue. - This might indicate adverse reactions but is not the most critical concern after administering hydrocodone/acetaminophen.
D. Assess the skin daily for areas of ecchymosis or other signs of bleeding. - While monitoring for bleeding is important, it's not the immediate concern following administration of hydrocodone/acetaminophen.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today