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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Free Nursing Study Resources

Correct Answer is E,C,B,D,A

Explanation

E. Disconnect the tube from the suction device:

Before starting the removal process, it's essential to disconnect the tube from any suction to prevent discomfort or injury to the client during removal.

C. Instill 50 mL of air into the tube:

Instilling air into the tube helps clear any residual contents and lubricates the tube, making it easier and more comfortable to remove.

B. Ask the client to take a deep breath:

Instructing the client to take a deep breath helps relax the throat and upper esophageal muscles, making the removal process smoother and potentially less uncomfortable.

D. Pinch and withdraw the tube:

Withdrawing the tube while the client holds their breath aids in a controlled removal, minimizing discomfort or risk of aspiration.

A. Apply clean gloves:

Lastly, applying clean gloves ensures infection control and maintains cleanliness during the removal process, preventing any potential contamination.

A. Have the client sign an against medical advice form. B. Tell the client that the surgeon will prescribe restraints if they try to leave. C. Explain to the client that they cannot leave until the surgeon discharges them. D. Administer a sedative medication to the client.

Correct Answer is C

Explanation

Choice A Reason:

Have the client sign an against medical advice (AMA) form is incorrect. While this form allows patients to leave against medical advice after acknowledging the risks, it should be used after thorough discussion, ensuring the patient understands the consequences. In this case, the client is postoperative and might not have received clearance from the surgeon, so this option may not be appropriate without further assessment.

Choice B Reason:

Tell the client that the surgeon will prescribe restraints if they try to leave is incorrect. Threatening restraints is not a suitable or ethical approach. Using restraints should be a last resort for ensuring safety, especially if a patient is attempting to leave. It's crucial to communicate and engage in dialogue rather than resorting to threats or coercion.

Choice C Reason:

Explain to the client that they cannot leave until the surgeon discharges them is correct. This action prioritizes the safety and well-being of the client while also informing them of the necessary procedure before leaving the hospital. It's essential to communicate the discharge process and ensure that the client understands the potential risks of leaving without proper medical approval. This approach maintains respect for the client's autonomy while emphasizing the importance of following the medical protocol for a safe recovery.

Choice D Reason:

Administer a sedative medication to the client is incorrect. Using sedatives to prevent a patient from leaving is not ethically or medically appropriate unless there's a critical situation where the patient is a danger to themselves or others. Administering sedatives without proper justification or consent violates ethical principles and could potentially harm the patient.

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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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Explanation

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