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 C
Explanation
Answer: C
Rationale:
A) Apply a topical corticosteroid ointment to the scalp: Corticosteroids are not indicated for the treatment of Pediculosis capitis (head lice). The treatment focuses on eliminating the lice and nits, typically through pediculicide medications like permethrin or ivermectin. Corticosteroids are used to reduce inflammation and itching, but they do not kill the lice or their eggs.
B) Soak hair brushes and combs in soapy water: Soaking hair brushes and combs in soapy water alone is not sufficient to kill lice. Items such as hair brushes should be soaked in hot water (130°F or higher) for at least 5-10 minutes to ensure any lice or nits present are killed. This is a critical step to prevent reinfestation.
C) Wash the bed linens in hot water: Washing bed linens in hot water (130°F or higher) is essential to eliminate lice and nits that may have transferred onto bedding. This prevents the spread and recurrence of lice. Items that cannot be washed should be sealed in a plastic bag for 2 weeks to kill the lice.
D) Clean the child's toys with a 1:10 bleach solution: Lice are spread through direct contact and cannot live on inanimate objects for long periods. Cleaning toys with bleach is unnecessary for lice removal and can be harmful to the toys or the child if not properly rinsed.
Correct Answer is C
Explanation
c. Hallucination
In the scenario described, the client's experience of receiving special audible messages from the Central Intelligence Agency that no one else can hear indicates a hallucination. Hallucinations are perceptual disturbances in which a person experiences sensory perceptions without any external stimuli. They can occur in any sensory modality, such as hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), tasting (gustatory hallucinations), or feeling (tactile hallucinations).
In this case, the client is experiencing auditory hallucinations, as he is perceiving auditory stimuli (audible messages) that are not present in the external environment. Auditory hallucinations are most commonly associated with schizophrenia, although they can occur in other psychiatric disorders as well.
Derealization (option a) refers to a subjective feeling of unreality or detachment from the environment. It involves a perception that the external world is strange, distorted, or unreal. This is not the primary alteration in perception described in the scenario.
Illusion (option b) is a misinterpretation or misperception of a real sensory stimulus. It occurs when a person's perception of an actual stimulus is distorted or misunderstood. There is no indication of a misperception of a real stimulus in the scenario.
Depersonalization (option d) is a subjective experience of being detached from one's own body, thoughts, or emotions. It involves a feeling of being outside of oneself or observing oneself from a distance. This is not the primary alteration in perception described in the scenario.
Therefore, the correct answer is c. Hallucination, as the client's experience of receiving special audible messages that no one else can hear represents an auditory hallucination.
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