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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The chain of infection describes how an infection spreads based on six links of transmission: Infectious Agent, Reservoirs, Portal of Exit, Modes of Transmission, Portal of Entry, and Susceptible Host1. In this case, the client’s mouth is an example of a portal of entry, which is the route by which an infectious agent enters a new host1.
Correct Answer is A
Explanation
Answer: A
Rationale:
A) A client who has hemorrhoids: An oral temperature is appropriate for this client as there are no contraindications for using the oral route. Hemorrhoids do not affect the accuracy or safety of oral temperature measurement.
B) A client who had recent oral surgery: Oral temperature measurement should be avoided for this client as it may cause discomfort or disrupt the healing process. Alternative routes, such as tympanic or axillary, are more appropriate.
C) A client who has a coagulation disorder: Oral temperature measurement might be risky in clients with coagulation disorders due to the potential for trauma or bleeding from the oral mucosa. A non-invasive method is preferable for safety.
D) A client who is drinking ice water: Drinking ice water can temporarily lower the temperature in the oral cavity, leading to inaccurate readings. The nurse should wait 15–30 minutes before measuring an oral temperature.
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