A nurse is assessing a client's oxygen saturation level using a pulse oximeter. Which oxygen saturation level indicates the need for immediate intervention?

95%

92%

89%

86%

Answer and Explanation

The Correct Answer is D

Answer: d. 86%

Explanation: An oxygen saturation level of 86% indicates severe hypoxemia and requires immediate intervention to ensure adequate oxygenation.

a. Oxygen saturation levels of 95% are within the normal range and do not require immediate intervention.

b. Oxygen saturation levels of 92% are relatively low but may not require immediate intervention depending on the client's clinical condition.

c. Oxygen saturation levels of 89% indicate significant hypoxemia and require intervention, but immediate intervention is required at a level of 86%.

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Correct Answer is C

Explanation

Answer: c. Swipe the thermometer gently across the client's forehead.

Explanation: Temporal artery thermometers are used by swiping the thermometer gently across the client's forehead. The device measures the temperature of the temporal artery, which correlates with core body temperature.

a. Inserting the thermometer into the rectum is not the appropriate method for using a temporal artery thermometer.

b. Placing the thermometer in the axilla is appropriate for axillary temperature measurement but not for temporal artery thermometers.

d. Holding the thermometer under the tongue is appropriate for oral temperature measurement but not for temporal artery thermometers.

A. Recheck the blood pressure using a different cuff size. B. Document the blood pressure findings as the only action required. C. Administer an antihypertensive medication immediately. D. Notify the healthcare provider of the elevated blood pressure.

Correct Answer is D

Explanation

Answer: d. Notify the healthcare provider of the elevated blood pressure.

Explanation: A blood pressure reading of 160/100 mmHg indicates hypertension and requires further evaluation by the healthcare provider to determine appropriate management.

a. Rechecking the blood pressure with a different cuff size may be appropriate if the initial reading was inaccurate, but it does not address the elevated blood pressure result.

b. Documenting the finding is important, but further action is required for elevated blood pressure.

c. Administering antihypertensive medication without consulting the provider is not appropriate; medication decisions should be made by the healthcare provider.

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A nurse is assessing a client's oxygen saturation level using a pulse oximeter. Which oxygen saturation level indicates the need for immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's body temperature using a temporal artery thermometer. How should the nurse use the temporal artery thermometer?

Correct Answer is C

Explanation

During a physical assessment, the nurse observes that a client's blood pressure is 160/100 mmHg. What action should the nurse take?

Correct Answer is D

Explanation

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