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 B

Explanation

A) Allowing the infant to have soft foods is not recommended immediately following surgery to protect the surgical site.

B) Maintaining elbow restraints prevents the infant from touching or injuring the repair site, which is crucial for proper healing.

C) Feeding the infant with a spoon could disrupt the surgical site and is not advised until cleared by a healthcare provider.

D) While oral hygiene is important, brushing the infant's teeth could harm the repair site; however, specific post-operative care instructions regarding oral hygiene should be provided by the healthcare provider, which may or may not include a temporary cessation of brushing.

A. The television set is turned to a loud volume. B. The dining room table has low chairs with no armrests. C. The bedroom extension cord is placed under a heavy nightstand. D. The living room contains wall-to-wall carpeting.

Correct Answer is C

Explanation

A. The television set turned to a loud volume may not necessarily pose a safety hazard unless it disturbs others in the household or contributes to hearing damage. However, it is not a direct safety concern for the client.
B. The dining room table having low chairs with no armrests could present a challenge for older adults when sitting down or getting up, but it is not an immediate safety hazard.
C. The bedroom extension cord placed under a heavy nightstand is a safety hazard because it poses a risk of electrical fire if the cord becomes damaged or overloaded. The nurse should
intervene to relocate the extension cord to a safer location.

D. The presence of wall-to-wall carpeting in the living room is not necessarily a safety hazard unless it is loose or torn, posing a tripping hazard. However, it is not explicitly described as such in the scenario.

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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?

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