A nurse is caring for a postoperative client and obtains a pulse oximeter reading of 89%. Which of the following interventions should the nurse take first?

Notify the primary care provider of the results.

Document the finding in the medical record.

Repeat the test on another finger.

Consult the respiratory therapist.

Answer and Explanation

The Correct Answer is C

A. Notify the primary care provider of the results: Notifying the provider is important for persistent hypoxemia, but the nurse should first ensure the reading is accurate. Immediate action should confirm whether the low saturation reflects true hypoxemia or a measurement error.

B. Document the finding in the medical record: Documentation is part of standard care, but it does not address the potential acute hypoxemia. Recording should occur after verifying the reading and initiating appropriate interventions if needed.

C. Repeat the test on another finger: Pulse oximeter readings can be affected by poor perfusion, nail polish, cold extremities, or device malfunction. Repeating the test on a different finger or site helps confirm the accuracy of the measurement before taking further clinical actions.

D. Consult the respiratory therapist: Referral to a respiratory therapist may be indicated if hypoxemia persists, but it is not the first action. The nurse must first verify the accuracy of the SpO2 reading to determine whether urgent intervention is necessary.

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Correct Answer is B

Explanation

A. Assist the client with positioning for an ultrasound: Positioning for ultrasound is part of the preparation for amniocentesis, not a post-procedure intervention. After the procedure, the priority is monitoring the client for complications rather than repeating imaging unless clinically indicated.

B. Monitor the client for placental abruption: Amniocentesis carries a small risk of complications such as bleeding, cramping, or placental injury. Monitoring the client for signs of placental abruption, including vaginal bleeding, abdominal pain, and uterine tenderness, is an appropriate post-procedure action to ensure early detection and intervention.

C. Administer Rh.D immune globulin to the client: Administration of Rh.D immune globulin is indicated for Rh-negative clients to prevent isoimmunization. Since this client is Rh-positive, they do not require Rh immunoglobulin, so this action is not necessary.

D. Obtain an umbilical blood sample from the fetus: Umbilical blood sampling (cordocentesis) is a separate diagnostic procedure and is not part of routine amniocentesis. Post-procedure care focuses on maternal monitoring and fetal well-being rather than obtaining fetal blood immediately.

A. "Are you thinking of harming yourself?" B. "You made the right decision by calling the hotline." C. "Tell me more about what is going on in your life." D. "Is there anyone with you right now?"

Correct Answer is A

Explanation

A. "Are you thinking of harming yourself?": Directly assessing for suicidal ideation is the immediate priority when a caller expresses hopelessness or statements suggesting despair. Asking clearly and directly about self-harm does not increase suicide risk and allows the nurse to determine intent, plan, and urgency. Early identification of suicidal thoughts is essential.

B. "You made the right decision by calling the hotline.": Offering reassurance and support is therapeutic, but it does not immediately assess the level of suicide risk. While validation can build rapport, determining whether the client is at imminent risk of self-harm takes priority over supportive statements.

C. "Tell me more about what is going on in your life.": Encouraging the client to elaborate is helpful for understanding stressors and emotional context. However, when suicidal ideation is suspected, directly assessing for self-harm risk must occur first to determine immediate safety needs before exploring background details.

D. "Is there anyone with you right now?": Determining whether the client is alone is important in crisis management, particularly if suicide risk is confirmed. However, this question should follow direct assessment of suicidal intent so that the nurse understands the level of immediate danger before addressing environmental support.

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A nurse is caring for a postoperative client and obtains a pulse oximeter reading of 89%. Which of the following interventions should the nurse take first?

Nursing Test Bank

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