While the nurse tries to obtain a sputum specimen from the client who has pneumonia, the client's SaO2 falls to 88%. Which intervention does the nurse implement next?
1. Complete the sputum collection quickly.
2. Clear the client's airway with suctioning.
3. Provide prescribed supplemental oxygen.
4. Instruct client to lie flat and breathe deeply.
3
3 and 1. The nurse stops the procedure, provides supplemental oxygen, and instructs the client to take several slow, deep breaths to restore oxygen saturation because 88% is too low because it is equivalent to a PaO2 of less than 80 mm Hg.
2. If the airway is compromised, the nurse should suction the airway. This client does not have a compromised airway.
4. The nurse helps the client to semi-Fowler's or high-Fowler's position, whichever is most comfortable for the client, to facilitate chest expansion. The nurse avoids the supine position because lying flat increases the work of breathing.
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When planning to conduct an interview with an inpatient client, which of the following would the nurse consider?
1. Reading the physician's notes 2. Staffing shortages on the unit 3. Asking the client if it is a good time to talk 4. Location for the interview
The nurse lowers the bed to place the patient on the bedpan. The angle of the head of the bed should be raised to:
a. 20 degrees. b. 45 degrees. c. 90 degrees. d. 30 degrees.
A client is prescribed an anticonvulsant. Why should the nurse advise the client not to stop taking the drug abruptly?
A) It may cause loss in appetite. B) It may trigger status epilepticus. C) It may cause alopecia. D) It may cause severe and ugly skin rashes.
The nurse is performing a focused interview with the client. Which behaviors indicate that the client may be feeling threatened?
1) The client begins to wiggle their foot back and forth. 2) The client frequently moves around in their chair. 3) The client crosses his arms and becomes very quiet. 4) The client leans forward in the chair making eye contact. 5) The client expresses anger when answering the questions.