A nurse has obtained a client's oxygen saturation measurement of 88% on 2 liters of oxygen via nasal cannula. Which of the following actions should the nurse take?

Check the client's heart rate on the oximeter.

Compare the result with the baseline reading.

Decrease the amount of oxygen administered.

Perform another reading while the client ambulates.

Answer and Explanation

The Correct Answer is B

A. Checking the client’s heart rate on the oximeter may provide additional data but does not address the low oxygen saturation or guide immediate intervention.
B. Comparing the result with the baseline reading helps determine if the 88% saturation is a sudden drop or consistent with the client’s usual oxygenation status, guiding further actions.
C. Decreasing the amount of oxygen would be inappropriate, as the client is already experiencing low oxygen saturation. Increasing oxygen may be necessary based on provider orders.
D. Performing another reading while the client ambulates could further decrease oxygen levels and is not an appropriate immediate action. Oxygenation should be assessed at rest before considering exertion.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Correct answers:

1. pulmonary edema

2. shallow rapid breaths

A. "You can use an adhesive remover when changing the colostomy skin barrier." B. "You should scrub the skin around the colostomy when cleaning." C. "You will need a device to suction stool from the colostomy bag." D. "You should empty the colostomy bag when it is three-fourths full."

Correct Answer is A

Explanation

A. Using an adhesive remover can help gently remove the colostomy appliance without causing skin irritation or damage. It can aid in maintaining skin integrity around the stoma.
B. Scrubbing the skin around the colostomy can cause skin trauma and increase the risk of infection. Gentle cleansing with warm water and mild soap is recommended.
C. There is typically no need to suction stool from a colostomy bag. Stool drainage occurs naturally into the bag, and suctioning is not a routine part of colostomy care.

D. Colostomy bags should be emptied when they are about one-third to one-half full to prevent

leakage and ensure comfort for the client. Waiting until the bag is three-fourths full may increase the risk of accidental leakage.

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A nurse has obtained a client's oxygen saturation measurement of 88% on 2 liters of oxygen via nasal cannula. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to care for a client on the medical unit. Exhibits Complete the following sentence by using the lists of options. The client is at risk for developing dropdown as evidenced by the client's dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

A nurse is reinforcing teaching with a client about caring for a new colostomy. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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