A nurse is caring for a 58-year-old client who has a low oxygen saturation. The nurse is reviewing the client's data to create a plan of care. Complete the diagram by drawing arrows to connect the condition and two parameters the nurse should monitor to assess the client's progress.
Low oxygen saturation -> Respiratory rate and heart rate
Low oxygen saturation -> Blood pressure and temperature
Low oxygen saturation -> Lung sounds and chest expansion
Low oxygen saturation -> Hemoglobin and hematocrit
The Correct Answer is C
Choice A reason: Respiratory rate and heart rate are not specific indicators of oxygen saturation. They can be affected by many other factors, such as pain, anxiety, or dehydration.
Choice B reason: Blood pressure and temperature are not directly related to oxygen saturation. They can be influenced by other conditions, such as infection, inflammation, or shock.
Choice C reason: Lung sounds and chest expansion are relevant parameters to monitor for a client with low oxygen saturation. They can indicate the presence of respiratory problems, such as pneumonia, asthma, or atelectasis, that can impair gas exchange and oxygen delivery.
Choice D reason: Hemoglobin and hematocrit are measures of red blood cell count and volume. They can affect the oxygen-carrying capacity of the blood, but they are not directly affected by oxygen saturation. They can be altered by other factors, such as bleeding, dehydration, or anemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is correct because hemoglobin A1C level reflects the average blood glucose level over the past 2 to 3 months. It is a reliable indicator of the patient's glycemic control and adherence to the antidiabetic therapy. The goal for most patients with type 2 diabetes is to keep the hemoglobin A1C level below 7%.
Choice B reason: This is incorrect because serum insulin level is not a good measure of the patient's adherence to the antidiabetic therapy, as it may vary depending on the type, dose, and timing of the insulin or oral antidiabetic agents. Serum insulin level may also be affected by other factors, such as stress, infection, or exercise.
Choice C reason: This is incorrect because fingerstick fasting blood glucose level only reflects the blood glucose level at a single point in time. It does not provide information about the patient's long-term glycemic control or adherence to the antidiabetic therapy. Fingerstick fasting blood glucose level may also be influenced by the patient's diet, activity, or medication intake before the test.
Choice D reason: This is incorrect because hemoglobin level is not related to the patient's adherence to the antidiabetic therapy, as it measures the amount of oxygen-carrying protein in the red blood cells. Hemoglobin level may be affected by conditions such as anemia, dehydration, or blood loss.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because lispro insulin is a rapid-acting insulin that does not need to be administered with another type of insulin. However, the patient may need a long-acting or intermediate-acting insulin to provide basal coverage throughout the day.
Choice B reason: This is incorrect because lispro insulin has a peak action of 30 to 90 min after the injection, which means that the patient is at the highest risk of hypoglycemia during this time. The nurse should assess for hypoglycemia more frequently than 4 hr after the injection.
Choice C reason: This is correct because lispro insulin has a fast onset of action of 15 to 30 min after the injection, which means that the patient should eat a meal within 15 min of the injection to prevent hypoglycemia.
Choice D reason: This is incorrect because polyuria is a sign of hyperglycemia, not hypoglycemia. The nurse should monitor for polyuria before the insulin injection, as it may indicate that the patient's blood glucose level is high.
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