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 B
Explanation
b. A client who has hemiparesis and lives alone.
Explanation:
The correct answer is b. A client who has hemiparesis and lives alone.
An interdisciplinary care conference involves the collaboration of multiple healthcare professionals from different disciplines to develop a comprehensive care plan for a client. In this scenario, the client with hemiparesis who lives alone requires an interdisciplinary care conference because their condition and living situation present complex challenges.
Clients who had surgery for cataract removal and live in a rural location (option a) may require support with transportation and follow-up appointments, but it does not necessarily warrant an interdisciplinary care conference.
A client who requires assistance to pay for dressing supplies (option c) may benefit from financial counseling or resources, but it does not typically require the involvement of multiple healthcare professionals in a care conference.
A client who requires instruction regarding medication administration (option d) can typically receive education from a nurse or pharmacist without the need for an interdisciplinary care conference.
In contrast, the client with hemiparesis who lives alone may require input from various professionals such as physical therapists, occupational therapists, social workers, and home healthcare providers to address their physical limitations, safety concerns, and support needs. Therefore, an interdisciplinary care conference is necessary to develop a comprehensive discharge plan that addresses all aspects of their care and promotes their well-being in the community.
Correct Answer is C
Explanation
Echolalia is the repetition of words or phrases spoken by others. In this case, the client is repeating the nurse's question, "How are you?" This is an example of echolalia.
a) "I am lovistrated" is an example of neologism, which is the creation of new words.
b) "Super, trooper, and duper" is an example of clang association, which is the use of words that sound alike but have no logical connection.
d) "Pink spots in Africa" is an example of a thought disorder, which is a disruption in the organization and expression of thoughts.
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.