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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The statement by the parent that they can place a rolled towel on each side of their newborn's head until he can hold his head up indicates an understanding of the teaching. This is a safe and appropriate way to provide support for the newborn's head while in a car seat.
a) Securing the seatbelt across the newborn's lap is not safe. The seatbelt should be positioned across the newborn's chest and over their hips.
b) Moving a child to a booster seat when they weigh 20 pounds is not safe. Children should remain in a rear-facing car seat until they are at least 2 years old or until they reach the highest weight or height allowed by the car seat's manufacturer.
c) Turning the car seat forward-facing when the child is 10 months old is not safe. Children should remain in a rear-facing car seat until they are at least 2 years old or until they reach the highest weight or height allowed by the car seat's manufacturer.
Correct Answer is A
Explanation
Immunocompromised individuals have a weakened immune system, which makes them more susceptible to infections. Soiled linens, when placed on the floor, can potentially harbor pathogens and become a source of contamination. It is essential to handle soiled linens properly by placing them in designated containers or bags to prevent the spread of infectious agents.
Uncapped sharps put in a puncture-resistant container: This is the correct practice for disposing of sharps, such as needles or lancets. Uncapped sharps should always be placed in puncture-resistant containers to prevent accidental injuries and potential transmission of infections.
Dampened cloths used for dusting the area: Dampened cloths for dusting can help minimize the dispersal of dust and allergens, but it does not necessarily pose a significant risk of infection.
However, it is important to ensure that the dampened cloths are properly cleaned and sanitized to prevent the growth and spread of microorganisms.
Waste containers lined with single bags: Waste containers lined with single bags are a common practice for proper waste management and disposal. While it is important to maintain good waste management practices to prevent the spread of infections, the use of single bags alone does not significantly affect the risk of infection for immunocompromised clients.
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