A nurse caring for a child who is receiving oxygen therapy and is on a continuous oxygen saturation monitor that is reading 89%. Which of the following actions should the nurse take first?
Place the child in the Fowler's position.
Ensure proper placement of the sensor probe.
Increase the oxygen flow rate.
Encourage the child to take deep breaths.
The Correct Answer is B
Choice A reason: While the Fowler's position can aid in breathing, it is not the first action to take if the oxygen saturation monitor is reading low.
Choice B reason: Ensuring the proper placement of the sensor probe is the first step, as incorrect placement can lead to inaccurate readings.
Choice C reason: Increasing the oxygen flow rate should only be considered after confirming the accuracy of the oxygen saturation reading.
Choice D reason: Encouraging deep breaths may be helpful, but it is not the first action to take. The priority is to ensure the oxygen saturation reading is accurate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A reason: Increased urinary output is not typically associated with heart failure. In fact, reduced urinary output may be expected due to decreased kidney perfusion.
Choice B reason: Nasal flaring is a sign of respiratory distress and can be expected in infants with heart failure as they struggle to maintain oxygenation.
Choice C reason: Peripheral edema is a common finding in heart failure due to fluid retention and poor circulation.
Choice D reason: Bradycardia is not a typical sign of heart failure in infants; tachycardia is more common. However, bradycardia can occur in advanced stages due to poor cardiac output.
Choice E reason: Cool extremities are indicative of poor perfusion, which is a consequence of decreased cardiac output in heart failure.
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: The inability to retract foreskin is not typically associated with epispadias. This condition is characterized by the urethral opening being on the dorsal side of the penis.
Choice B reason: In epispadias, the urethral opening is located on the dorsal side of the penis, which is a key characteristic of this condition.
Choice C reason: A widened pubic symphysis is often seen in epispadias due to the associated pelvic bone structure abnormalities.
Choice D reason: Bladder exstrophy is commonly associated with epispadias and involves the bladder being exposed outside the abdomen.
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