Nokea
A patient with a pulse oximetry reading of 88% requires which intervention?
- A. Encourage coughing
- B. Administer oxygen
- C. Reposition the patient
- D. Check temperature
Correct Answer: B
Rationale: A pulse oximetry of 88% indicates hypoxemia (normal is 95-100%). Administering oxygen is the priority to correct low oxygen levels, over coughing, repositioning, or checking temperature.
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A client with anemia presents with fatigue and decreased exercise tolerance. What is the primary indication for initiating oxygen therapy in this client?
- A. Increasing oxygen-carrying capacity
- B. Reducing iron deficiency
- C. Promoting tissue healing
- D. Enhancing erythropoiesis
Correct Answer: A
Rationale: In a client with anemia, the primary indication for oxygen therapy is to increase the oxygen-carrying capacity of the blood and improve tissue oxygenation.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
- A. Discuss the risk factors for colon cancer.
- B. Focus teaching on what the client will need to do in the future to manage his illness.
- C. Provide the client with written information about the phases of loss and grief
- D. Reassure the client that this is an expected response to grief.
Correct Answer: D
Rationale: Reassure the client that this is an expected response to grief. The client might perceive the discussion of risk factors as challenging or argumentative, the nurse should focus the teaching on the present psychosocial adaptation and not the future management, unless the client requests material this is not a good time, this is when the client needs to express their feelings.
A nurse is caring for a client receiving high-flow oxygen therapy via a noninvasive positive pressure ventilation (NPPV) device. What is an important nursing intervention for this client?
- A. Assessing the client's oxygen saturation every 4 hours
- B. Monitoring the client's respiratory rate every 15 minutes
- C. Providing frequent oral care to prevent dry mouth
- D. Administering oxygen at a flow rate of 1-2 L/min
Correct Answer: C
Rationale: NPPV devices, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP), can cause dry mouth. Providing frequent oral care, such as mouth rinses and moisturizing agents, helps alleviate discomfort and prevent oral complications.
The nurse is performing nasotracheal suctioning of a client. What should the nurse do when suctioning this client?
- A. Apply suction for 5-10 seconds.
- B. Plan to suction for 10 minutes.
- C. Apply suction while inserting the catheter.
- D. Apply suction for 20-30 seconds.
Correct Answer: A
Rationale: Nasotracheal suctioning should apply suction for 5-10 seconds (A) to minimize hypoxia and trauma with intermittent suctioning. Suctioning for 10 minutes (B) is excessive and dangerous. Applying suction during insertion (C) risks mucosal damage. 20-30 seconds (D) is too long increasing hypoxia risk making A the correct technique.
A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?
- A. Examine personal values about the issue.
- B. Tell the parents that this is a necessary procedure.
- C. Inform the parents that the staff does not require their consent.
- D. Contact a spiritual support person to explain the importance of the procedure.
Correct Answer: A
Rationale: Examine personal values about the issue. Nurses should give care that is without bias. The nurse should provide information but not push care as 'necessary', parents must give consent for blood transfusions, and the provider should give information about the procedure not a spiritual support person.