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 B
Explanation
The correct answer is b.
Choice A: SpO2 95%
The normal range for SpO2, or peripheral capillary oxygen saturation, is typically between 95% and 100%. While a SpO2 of 95% is within the normal range, it doesn't necessarily indicate an understanding of vital signs as it's on the lower end of the normal range.
Choice B: Right radial pulse regular 68/min
The normal resting heart rate for adults ranges from 60 to 100 beats per minute. Therefore, a right radial pulse of 68 beats per minute falls within the normal range and indicates an understanding of vital signs.
Choice C: Temp 36°C (96.8°F)
The normal body temperature for a healthy adult can range from 97.8°F (36.5°C) to 99.1°F (37.3°C). Therefore, a body temperature of 36°C (96.8°F) is slightly below the normal range.
Choice D: BP 148/72 mm Hg
The normal range for blood pressure in adults is between 90/60 mmHg and 120/80 mmHg. A blood pressure reading of 148/72 mm Hg is above the normal range for systolic pressure (the top number), indicating high blood pressure (hypertension).
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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