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","B","C","D","E"]
Explanation
Correct answers:
Nurses Notes Day 1, 1600:
Alert and oriented x3. Pupils equal, round, reactive to light, accommodation at 3 mm. Heart rate 150/min, ECG monitor showing sinus tachycardia, 5, auscultated. Lower extremity edema noted, 2+ bilaterally. Radial and pedal pulses 1 bilaterally. Breathing rapid and shallow. Cracklesauscultated in bases bilaterally. Bowel sounds normoactive in all four quadrants. Reports no difficulty urinating.
Client reports gaining "10 pounds in the past month."
Correct Answer is A
Explanation
- A: Completing an incident report is an important step after addressing any immediate risks to the patient. It is a part of the process to document errors and prevent future occurrences, but it does not take precedence over the patient's immediate safety.
- B: Allowing the current solution to finish could harm the patient, depending on the contents of the IV solution and the patient's condition. Immediate action is required to prevent potential adverse effects.
- C: Documentation in the medical record is crucial, but it should be done after the error has been corrected and the patient's safety is ensured. The immediate priority is to address the error.
- D: Stopping the infusion is the most immediate and appropriate action to prevent further harm to the patient. Once the infusion is stopped, the nurse can then take further steps to correct the error and follow up with the necessary documentation and reports.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.