A home health nurse is assisting in the care of a client.

Exhibits

Select the 4 findings that indicate an understanding of the reinforced teaching

A. Check the client's medical records to see which medications were recently administered:
While reviewing medications is important for understanding potential causes of hypoxia, it is not the immediate priority when a client’s oxygen saturation is low. Immediate assessment and intervention to improve oxygenation come first.

B. Notify the charge nurse of the client's condition: Notifying the charge nurse is important but should follow an initial assessment and attempt to address the problem. Immediate client reassessment takes precedence to determine the current status and possible interventions.

C. Review the client's most recent SaO2 level in the medical record: Checking prior oxygen saturation levels can provide context but does not directly address the acute finding of 88% saturation, which requires prompt evaluation and action.

D. Recheck the client's SaO2 level after having the client cough and clear their throat: This action directly addresses a common cause of transient hypoxia such as airway obstruction from secretions. Reassessment after clearing the airway is the priority to determine if oxygenation improves before escalating interventions.

A. Explain that the treatment is both safe and therapeutic: Providing reassurance about the safety and effectiveness of the procedure may be informative, but it can unintentionally pressure the client to consent. It does not respect the client’s autonomy or support their right to make independent healthcare decisions.

B. Tell the client that the procedure is necessary: Telling the client a procedure is necessary can sound coercive and may disregard their legal and ethical right to refuse treatment. Nurses must prioritize respecting the client's decisions, even if those decisions involve refusing recommended medical care.

C. Notify the client's loved ones of the client's refusal of the procedure: Informing family members without the client’s consent may breach confidentiality and is not appropriate unless the client is unable to make informed decisions. Client autonomy must be preserved, and their refusal should be respected unless there is an immediate risk of harm.

D. Inform the client they have the right to refuse treatment: Clients have the legal and ethical right to refuse any medical intervention, even if it is life-sustaining. The nurse’s role includes advocating for the client’s autonomy, ensuring informed consent, and supporting their decision without judgment or pressure.