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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?
- A. Complete the intermittent suction of the nasopharynx.
- B. Apply an oxygen mask over the client's nose and mouth.
- C. Reposition the pulse oximeter clip to obtain a new reading.
- D. Stop suctioning until the pulse oximeter reading is above 95%.
Correct Answer: A
Rationale: Stable saturation allows safe continuation of suctioning.
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After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?
- A. Discontinue the use of the nasal cannula.
- B. Apply lubricant to the cannula tubing.
- C. Place padding around the cannula tubing.
- D. Decrease the flow rate to 1 L/minute.
Correct Answer: C
Rationale: Padding prevents skin breakdown.
An older adult client returns to the clinic for chronic pain management after taking morphine sulfate 25 mg PO every 12 hours. The client reports taking the medication only when the pain was too severe to sleep. Which action should the nurse implement?
- A. Teach the client alternative ways to manage chronic pain.
- B. Instruct the client to take the morphine sulfate every 12 hours as prescribed.
- C. Tell the client to continue taking the morphine sulfate with severe pain.
- D. Explain the risk of drug addiction from long-term pain medications.
Correct Answer: B
Rationale: Scheduled dosing maintains consistent pain control.
A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement?
- A. Orient the client to their surroundings.
- B. Close the client's room door.
- C. Escort the client back to the room.
- D. Raise the four side rails on the bed.
- E. Secure a bed alarm on the mattress.
Correct Answer: A,C,E
Rationale: Orientation, escort, and alarm ensure safety.
When a home health nurse is administering a 10-day prescription for intermittent infusions of daptomycin to a client with Staphylococcus aureus cellulitis, the client inquires why the pharmacy delivered only a few of the premixed bags and not all of the doses. Which response should the nurse provide to the client?
- A. The medication is in short supply at the local pharmacy.
- B. The antibiotic has a limited shelf life after reconstitution.
- C. The healthcare provider should be notified of the discrepancy.
- D. The instructions may change over the course of therapy.
Correct Answer: B
Rationale: Daptomycin has short stability post-reconstitution.
A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?
- A. Skin turgor.
- B. Weight.
- C. Blood pressure.
- D. Lung sounds.
Correct Answer: B
Rationale: Daily weight accurately tracks fluid balance.