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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will take a stool softener to prevent constipation." This is correct. Postoperative clients, especially those who are on opioid medications for pain management, are at risk for constipation. Taking a stool softener is a good strategy to prevent this complication after surgery.
B. "I will ask to work the night shift, so I will not be driving in bright sunlight." This is incorrect. Following laser surgery for open-angle glaucoma, clients are typically advised to avoid bright lights and glare, but there is no need to change work schedules. The focus should be on wearing protective sunglasses to shield the eyes from sunlight and glare, not on avoiding daytime work hours.
C. "I will need to use my eye drops for 1 year." This is incorrect. While eye drops may be prescribed to manage intraocular pressure, the duration of use will depend on the specific medication and the client's condition. It is not typically necessary to use them for an entire year after laser surgery, and the client should follow the provider's instructions for tapering or stopping the medication as indicated.
D. "I will need to follow a low-protein diet." This is incorrect. There is no specific dietary restriction for a low-protein diet following laser surgery for open-angle glaucoma. The client should follow a balanced diet as recommended by the healthcare provider.
Correct Answer is B
Explanation
A. Hemoglobin (Hgb) of 12 g/dL is within the normal range for a pregnant individual and does not typically require notification of the provider.
B. Platelet count of 90,000/mm3 is below the normal range (typically 150,000 to 400,000/mm3) and may indicate thrombocytopenia, which can be associated with conditions such as
preeclampsia or HELLP syndrome. The nurse should notify the provider about this result.
C. Hematocrit of 37% is within the normal range for a pregnant individual and does not typically require notification of the provider.
D. Creatinine level of 0.7 mg/dL is within the normal range and does not typically require notification of the provider.
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