A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?

Recheck the client's SaO, level after having the client cough and clear their throat.

Review the client's most recent Sao, level in the medical record.

Notify the charge nurse of the client's condon.

Check the client's medical records to see which medications were recently administered.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Recheck the client's SaO2 level after having the client cough and clear their throat is correct. This action is crucial to ensure the accuracy of the SaO2 reading. Sometimes, minor obstructions or secretions in the airway can momentarily affect the oxygen saturation readings. Having the client cough and clear their throat may help improve the SaO2 readings by clearing any temporary blockages.

Choice B Reason:

Review the client's most recent SaO2 level in the medical record is incorrect. While reviewing the client's history is important, the immediate priority is to verify the current SaO2 level for accuracy before taking further action.

Choice C Reason:

Notify the charge nurse of the client's condition is incorrect. While it might eventually be necessary to inform other healthcare team members, the immediate action should focus on rechecking the SaO2 level to ensure the client's current oxygen saturation status.

Choice D Reason:

Check the client's medical records to see which medications were recently administered is incorrect. Knowing the client's recent medications is important for assessment, but it may not directly address the current situation of shortness of breath and low oxygen saturation. Rechecking the SaO2 level takes precedence in this acute situation.

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Correct Answer is C

Explanation

Correct Answer: C

C. Flex hips and knees when assisting the client to a standing position.Flexing the hips and knees protects the nurse’s back by using proper body mechanics and distributes the force of lifting safely. This position provides stability and reduces the risk of injury to both the nurse and the client during the transfer.

Incorrect answers:

A: "Stand on the client's stronger side when moving the client into the chair."The nurse should stand on the weaker side, not the stronger side, to provide support and assistance where it is most needed. This ensures the client is stabilized and prevents falls or instability due to the weaker side giving way.

B: "Pivot on the foot farthest from the bed when assisting the client into the chair."The nurse should pivot on the foot closest to the chair or the bed to maintain balance and stability. Pivoting on the farthest foot could lead to poor body mechanics and an increased risk of injury to the nurse or client.

D: "Raise the bed to waist level before moving the client." For transferring a client to a chair, the bed should be lowered to a position where the client’s feet can touch the floor. This provides stability and facilitates a safe transfer.

A. Hyperkalemia B. Hypocalcemia C. Hypermagnesemia D. Hyponatremia

Correct Answer is D

Explanation

Choice A Reason:

Hyperkalemia is incorrect. Vomiting and diarrhea typically lead to a loss of potassium rather than an increase. These conditions often result in depletion of electrolytes, including potassium, due to the loss of fluids.

Choice B Reason:

Hypocalcemia is correct. While prolonged or severe diarrhea could potentially lead to some electrolyte imbalances, hypocalcemia is not typically a primary finding associated with vomiting and diarrhea. Calcium levels may not be significantly affected by these symptoms compared to sodium and potassium.

Choice C Reason:

Hypermagnesemia is incorrect. Similar to calcium, magnesium levels are not usually significantly impacted by vomiting and diarrhea alone. Hypermagnesemia is more commonly associated with excessive intake of magnesium-containing medications or renal dysfunction rather than acute gastrointestinal symptoms.

In a client experiencing vomiting and diarrhea, the loss of fluids and electrolytes due to these symptoms commonly leads to:

Choice D Reason:

Hyponatremia is correct. Vomiting and diarrhea can cause a loss of sodium and water, leading to decreased sodium levels in the blood, which manifests as hyponatremia. This electrolyte imbalance is a typical finding in individuals experiencing gastrointestinal issues with fluid loss.

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A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?

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