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

Explanation

Choice A Reason:

"He appears anxious about the transfer."While this might be relevant in certain contexts, it is subjective and less critical compared to other clinical information. The transfer report should prioritize objective data that directly impacts the client’s care.

Choice B Reason:

"He is allergic to sulfa." Allergies are crucial information that must be communicated during any transfer. This ensures that the receiving healthcare team is aware and can avoid administering medications that could cause an allergic reaction. This is important information to include in the transfer report.

Choice C Reason:

"His partner has been visiting." While it may be helpful to know about the client’s support system, this information is not as critical as details about the client's health status, medications, or allergies.

Choice D Reason:

"He is voiding adequately." Voiding patterns can be relevant, particularly if there have been recent issues with urinary function or if the client is being monitored for urinary output. However, unless there is a specific reason this is critical to ongoing care, it may not be the most essential information to include.

A. Turn the client every 4 hr. B. Cleanse the perineal area with povidone-iodine solution. C. Apply cornstarch powder to the perineal area. D. Place a moisture barrier ointment over the perineal area.

Correct Answer is D

Explanation

Choice A Reason:

Turn the client every 4 hr. is incorrect. While repositioning is crucial for preventing pressure ulcers in immobile patients, turning the client every 4 hours might not directly address the issue of fecal incontinence or skin protection in the perineal area.

Choice B Reason:

Cleanse the perineal area with povidone-iodine solution is incorrect. Povidone-iodine solution might be too harsh for routine perineal care and can potentially irritate the skin. A gentler cleansing solution is typically recommended to avoid further skin irritation.

Choice C Reason:

Apply cornstarch powder to the perineal area is incorrect. Cornstarch powder might exacerbate moisture-related skin issues in the perineal area by creating a damp environment, potentially leading to skin maceration and worsening skin problems. It's not typically recommended for use in managing fecal incontinence.

Choice D Reason:

Place a moisture barrier ointment over the perineal area is correct. Using a moisture barrier ointment can help protect the skin from irritation and breakdown caused by prolonged exposure to fecal matter, reducing the risk of skin breakdown and discomfort.

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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

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Correct Answer is B

Explanation

A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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