A nurse is caring for a client who has an oxygen saturation of 88%. Which of the following actions should the nurse take?

Decrease the head of the client’s bed.

Encourage the client to take deep breaths.

Ask the client to cough every 4 hr.

Request a prescription for an opioid analgesic.

Answer and Explanation

The Correct Answer is B

An oxygen saturation of 88% is below the normal range of 95-100%, indicating that the client may be experiencing hypoxia. Encouraging the client to take deep breaths can help increase their oxygen saturation level.

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Correct Answer is C

Explanation

The nurse should expect to find an increased heart rate in a client with a fever. An elevated body temperature can cause an increase in metabolic rate, which can lead to an increase in heart rate. This is a normal physiological response to fever and helps the body to generate heat and fight oﬀ infection.

A. Localized warmth at the site of injury B. Sanguineous drainage at the site of injury. C. Palpable pedal pulses below the aﬀected injury site D. Full range of motion at the site of injury

Correct Answer is A

Explanation

Localized warmth is a classic sign of inﬂammation and can indicate the presence of an infection or injury in the aﬀected area. Sanguineous drainage is a type of wound drainage that consists of blood and is not a sign of inﬂammation. Palpable pedal pulses and full range of motion can provide information about the injury, but they are not specific to inﬂammation. Therefore, options b, c, and d are incorrect.

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A nurse is caring for a client who has an oxygen saturation of 88%. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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