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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A. Potassium
Rationale:
A) Potassium:
Furosemide is a loop diuretic that can cause significant potassium loss through increased urine output. Monitoring potassium levels is crucial to prevent hypokalemia, which can lead to serious cardiac arrhythmias and muscle weakness. Ensuring potassium levels remain within a normal range helps maintain the infant's overall health and safety while on this medication.
B) WBC Count:
While it is important to monitor WBC count in various clinical situations, furosemide does not typically affect white blood cell levels. Therefore, monitoring WBC count is not specifically indicated for infants receiving furosemide unless there is another underlying condition that requires it.
C) Iron:
Iron levels are not typically affected by furosemide. Monitoring iron levels would be more relevant in cases of anemia or other hematologic conditions. Furosemide does not interfere with iron metabolism, so this test is not a priority for infants on this medication.
D) Amylase:
Amylase is an enzyme related to the pancreas and is typically monitored in conditions such as pancreatitis. Furosemide does not have a direct effect on amylase levels, so monitoring this enzyme is not necessary for infants receiving this diuretic. The focus should be on electrolytes, particularly potassium.
Correct Answer is A
Explanation
A respiratory rate of 8 breaths per minute with shallow respirations and cyanosis indicates severe respiratory distress or failure. In this situation, the client's oxygenation is compromised, and immediate intervention is needed to ensure an open and unobstructed airway. The nurse should prioritize ensuring the client has a patent airway by assessing for any airway obstruction and taking appropriate measures to clear the airway if necessary. This may involve techniques such as the head tilt-chin lift or jaw thrust maneuver.
While administering oxygen, checking the client's pulse rate, and placing a pulse oximeter on the client's finger are all important interventions in managing respiratory distress, the first and most critical step is to establish a patent airway. Without a clear airway, the client's oxygenation cannot be adequately addressed, and other interventions may be ineffective. Once the airway is secured, the nurse can proceed with providing oxygen, assessing the client's vital signs, and monitoring oxygen saturation using a pulse oximeter.
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