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

Answer: B. Compare the result with the baseline reading

Rationale:

A. Check the client's heart rate on the oximeter:
Although checking the heart rate may provide context for assessing the client's overall status, it does not address the primary concern of the low oxygen saturation. Understanding the client's baseline saturation level takes priority to guide further actions effectively.

B. Compare the result with the baseline reading:
Comparing the reading with the client's baseline is essential. For clients with chronic respiratory conditions, baseline oxygen levels may naturally be lower. Identifying if this 88% saturation is typical or unusual for the client helps determine the need for further intervention or adjustment.

C. Decrease the amount of oxygen administered:
Reducing oxygen flow when the saturation is low is contraindicated, as it could worsen hypoxia. Instead, increasing oxygen may be warranted if the reading remains below the baseline after further assessment.

D. Perform another reading while the client ambulates:
Repeating the reading during ambulation may worsen hypoxia and is not ideal without understanding baseline oxygenation at rest. Re-evaluation at rest or in a different position may be more appropriate for accurate assessment.

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Free Nursing Study Resources

Correct Answer is C

Explanation

When administering a tap water enema, the client should be assisted to a right Sims position. This position involves lying on the left side with the right knee bent toward the chest.

The other options are not correct because:

a) The client should not bear down during rectal tube insertion.

b) Administering a second enema if results are not clear is not mentioned as a safety precaution.

d) The rectal tube should be inserted in the direction of the sacrum, not the umbilicus.

A. Start the first patch on the seventh day of the menstrual cycle. B. The contraceptive eﬀect will continue for 6 months following discontinuation of the medication C. Apply the patch to the lower abdomen D. Expect to have a headache during the first month

Correct Answer is C

Explanation

a. "Start the first patch on the seventh day of the menstrual cycle."

Explanation:

The correct answer is a. "Start the first patch on the seventh day of the menstrual cycle."

When providing teaching about a combination contraceptive transdermal patch, it is important to provide accurate and relevant information to ensure its eﬀectiveness and proper use.

Option b is not the correct answer. The contraceptive eﬀect of the transdermal patch does not continue for 6 months following discontinuation. Its eﬀectiveness lasts only as long as the client continues to use it according to the prescribed schedule.

Option c is not the correct answer. The transdermal patch should be applied to a clean, dry area of the skin that is free from cuts, rashes, or irritation. The lower abdomen is not a recommended site for application.

Option d is not the correct answer. While headaches can occur as a side eﬀect of hormonal contraceptives, it is not necessary to expect a headache during the first month. Side eﬀects can vary among individuals, and it is important to monitor and report any concerning symptoms to the healthcare provider.

By instructing the client to start the first patch on the seventh day of the menstrual cycle, the nurse provides specific guidance on when to initiate the contraceptive method. This ensures that the client is starting the patch at an appropriate time in their menstrual cycle, optimizing its eﬀectiveness

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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 reinforcing discharge teaching with an older adult client's family about safety precautions when administering a tap water enema to the client. Which of the following should the nurse include in the instructions?

Correct Answer is C

Explanation

A nurse in a clinic is reinforcing teaching with a client who has a new prescription for a combination contraceptive transdermal patch. Which of the following should the nurse include in the teaching?

Correct Answer is C

Explanation

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