While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

Complete the intermittent suction of the nasopharynx.

Apply an oxygen mask over the client's nose and mouth.

Reposition the pulse oximeter clip to obtain a new reading.

Stop suctioning until the pulse oximeter reading is above 95%.

Answer and Explanation

The Correct Answer is A

Choice A reason: If the oxygen saturation remains stable during the procedure, it indicates that the suctioning is not adversely affecting the client's oxygenation, and the nurse can safely continue.

Choice B reason: Applying an oxygen mask is not necessary if the oxygen saturation is stable and within a safe range.

Choice C reason: Repositioning the pulse oximeter clip is only necessary if there is a concern about the accuracy of the reading, not when the reading is stable.

Choice D reason: There is no need to stop suctioning if the oxygen saturation is stable at 94%, as this is within the acceptable range for most clients.

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Correct Answer is D

Explanation

Choice A reason: Offering comfort that healing can happen at any point in time may not be appropriate for a client in the terminal stage of lung cancer, as it may give false hope.

Choice B reason: Offering strategies to provide comfort to the client can be helpful, but it does not address the spouse's immediate emotional needs.

Choice C reason: Suggesting that the spouse go home to sleep may seem dismissive of the spouse's current emotional state and need for support.

Choice D reason: Explaining that the staff will strive to keep the client comfortable addresses the spouse's concern for the client's well-being and provides reassurance about the care being provided.

A. Exercise in the evening. B. Watch television in bed to fall asleep. C. Take an analgesic before bed. D. Avoid alcohol in the evening. E. Try to go to bed and awaken at the same time every day. F. Avoid naps. G. Eat a heavy meal before bed.

Correct Answer is ["D","E","F"]

Explanation

Choice A reason:
Exercising in the evening can actually be counterproductive for some people when it comes to sleep. While regular exercise is beneficial for overall health and can contribute to better sleep, doing it too close to bedtime can stimulate the body, making it harder to relax and fall asleep.

Choice B reason:
Watching television in bed is generally not recommended as part of good sleep hygiene. The light from the screen can interfere with the body's production of melatonin, the hormone that signals it's time to sleep, and engaging content can keep the brain alert rather than allowing it to wind down.

Choice C reason:
Taking an analgesic before bed is not a general recommendation for better sleep unless pain is a specific issue that is preventing sleep. It's important to address the root cause of insomnia rather than masking symptoms with medication.

Choice D reason:
Avoiding alcohol in the evening is a good practice for better sleep. Alcohol can disrupt the sleep cycle and lead to fragmented sleep, even though it may initially seem to help with falling asleep.

Choice E reason:
Going to bed and waking up at the same time every day helps to regulate the body's internal clock, or circadian rhythm, which can improve sleep quality. Consistency is key for this practice to be effective.

Choice F reason:
Avoiding naps, especially in the late afternoon or evening, can help ensure that you are sufficiently tired at bedtime. Napping can interfere with nighttime sleep if done too late in the day or for too long.

Choice G reason:
Eating a heavy meal before bed can lead to discomfort and indigestion, which can make it harder to fall asleep. It's best to have a light snack if needed and avoid large meals close to bedtime.

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While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is in the terminal stage of lung cancer. Outside the room, the client's spouse expresses to the nurse feelings of helplessness and a lack of hope for the future. How should the nurse respond?

Correct Answer is D

Explanation

Exhibits What other recommendations could the nurse give to help the patient have better sleep? Select all that apply.

Correct Answer is ["D","E","F"]

Explanation

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While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

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