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
Answer: (D) Refrigerate the specimen until the time of transport to the laboratory
Rationale:
A) Collect 2 ml of sputum in an emesis basin: While it is important to collect an adequate volume of sputum, using an emesis basin is inappropriate for collecting a specimen for culture and sensitivity. Sputum must be collected in a sterile container to avoid contamination, ensuring the accuracy of the culture results.
B) Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection: Using an antiseptic mouthwash before collecting a sputum specimen is not recommended, as it could contaminate the sample with antiseptic agents, potentially affecting the growth of microorganisms in the culture. The client should rinse with plain water instead.
C) Swab the oropharynx with a sterile swab: Swabbing the oropharynx is more appropriate for collecting a throat culture rather than a sputum specimen. Sputum collection requires the client to expectorate mucus from the lower respiratory tract, not from the oropharynx, to obtain an accurate sample for culture and sensitivity.
D) Refrigerate the specimen until the time of transport to the laboratory: Refrigerating the sputum specimen is crucial to preserve the integrity of the sample and inhibit the growth of contaminants before it is transported to the laboratory. This action helps ensure that the results of the culture and sensitivity test are accurate.
Correct Answer is B
Explanation
b. Methylergonovine.
Explanation:
Postpartum hemorrhage is a significant complication that can occur after childbirth. Methylergonovine is a medication commonly used to manage postpartum hemorrhage. It is an ergot alkaloid that helps to contract the uterus, reducing bleeding. It is typically administered either intramuscularly or orally.
Option a, Terbutaline, is a medication used for the management of preterm labor by relaxing the uterine smooth muscles. It is not indicated for postpartum hemorrhage.
Option c, Magnesium sulfate, is a medication used for the prevention and treatment of seizures in patients with preeclampsia or eclampsia. It is not specifically indicated for postpartum hemorrhage.
Option d, Nifedipine, is a calcium channel blocker commonly used to manage hypertension. It is not indicated for postpartum hemorrhage.
It's important to note that the specific management of postpartum hemorrhage may vary depending on the underlying cause, severity of bleeding, and individual patient factors. The healthcare provider will determine the most appropriate interventions and medications for each case.
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