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 B

No explanation

A. Discontinue supplements containing vitamin C 24 hr. before the test B. Refrain from consuming pork 7 days before the test. C. Place a thick layer of stool on the specimen card. D. Urinate prior to collecting the stool specimen

Correct Answer is D

Explanation

Choice A Reason:

Discontinuing supplements containing vitamin C 24 hr. before the test is incorrect. While high doses of vitamin C might interfere with the accuracy of some laboratory tests, it typically doesn't impact fecal occult blood testing. However, it's always best to follow specific instructions provided by the healthcare provider or laboratory.

Choice B Reason:

Refraining from consuming pork 7 days before the test. There isn't typically a requirement to avoid specific foods, such as pork, before a fecal occult blood test. The test is designed to detect blood in the stool, regardless of the diet. However, some dietary restrictions might be advised based on specific instructions or conditions, but these are not universally applicable.

Choice C Reason:

Placing a thick layer of stool on the specimen card is incorrect. When collecting a sample for a fecal occult blood test, it's important to follow the specific instructions provided by the healthcare provider or laboratory. Generally, a small portion of stool is applied to the designated area on the specimen card as instructed, rather than applying a thick layer. Applying too much stool can affect the accuracy of the test.

Choice D Reason:

Urinating prior to collecting the stool specimen is correct. This instruction ensures that the urine doesn't contaminate the stool sample, which could potentially affect the accuracy of the test results.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Correct Answer is B

A nurse is reinforcing discharge teaching about fecal occult blood testing with include in the teaching?

Correct Answer is D

Explanation

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