Nclex Examination Challenge Question & Answer Guide (With Explanation)

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Original Question

NCLEX EXAMINATION CHALLENGE 28.2 Safe and Effective Care Environment A nurse assessing an older adult client with pneumonia notes the client is now confused and the oxygen saturation has dropped since the last assessment 1 hour ago from 90% to 84%. The nurse also notes the respiratory rate has increased from 26 to 32. What is the nurse’s best first action? A. Encourage the client to use the incentive spirometer hourly. B Increase her 02 flow rate by 2 L and reassess in 5 minutes. C. Increase the flow rate of the IV antibiotic. D. Document the changes as the only action. INFECTION CONCEPT EXEMPLAR:

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