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 ["A","B","E"]

Explanation

Compartment syndrome is a condition characterized by increased pressure within a closed anatomical space, such as a compartment in the leg. This increased pressure can compromise blood ﬂow and nerve function. When assessing a client with a long-leg cast who reports severe pain, the nurse should be vigilant for signs and symptoms of compartment syndrome.

Option a is a correct answer because pallor (paleness) in the exposed portion of the left foot may indicate compromised blood ﬂow due to increased pressure within the compartment.

Option b is a correct answer because the inability to move the left foot suggests impaired nerve function,

which can be a sign of compartment syndrome.

Option c is not a correct answer. Increased warmth is not typically associated with compartment syndrome; instead, it may suggest inﬂammation or infection.

Option d is not a correct answer. Ecchymosis (bruising) is not typically associated with compartment syndrome, as it is more commonly observed in cases of injury or trauma.

Option e is a correct answer because paresthesia (abnormal sensations like tingling or numbness) in the left foot can indicate nerve compression and is a potential symptom of compartment syndrome.

By identifying the presence of pallor, inability to move the foot, and paresthesia, the nurse can recognize indications of compartment syndrome and take appropriate actions to address the condition promptly.

A. "Your nurse will provide information about the risks and benefits of surgical procedures." B. "Only health care staﬀ providing care will see your medical record." C. "The provider must grant you access to your personal health information." D. "You have to authorize our providers to prescribe treatments for your condition."

Correct Answer is B

Explanation

The nurse should include the statement that only health care staﬀ providing care will see the client's medical record when reinforcing teaching about confidentiality. This statement emphasizes the importance of maintaining the privacy and confidentiality of the client's personal health information.

Explanation for the other options:

a. "Your nurse will provide information about the risks and benefits of surgical procedures." While it is important for the nurse to provide information about surgical procedures, this statement does not specifically address confidentiality.

c. "The provider must grant you access to your personal health information." This statement is related to the client's rights regarding access to their personal health information. While it is important to educate clients about their rights, it is not specifically focused on confidentiality.

d. "You have to authorize our providers to prescribe treatments for your condition." This statement is related to obtaining the client's consent for treatment, which is important but not directly addressing confidentiality.

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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 collecting data from a client who has a long-leg cast on his left leg and reports severe pain. Which of the following findings should the nurse identify as an indication that the client might have compartment syndrome? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is reinforcing teaching about confidentiality with a client. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

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