A nurse is monitoring a client’s oxygen saturation using a pulse oximeter. The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula.
Which of the following actions should the nurse take?
Reposition the sensor probe.
Apply a cooling blanket to the client.
Place the client in a side-lying position.
Ambulate the client.
The Correct Answer is A
The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula, which is below the normal range of 95% to 100%.
This could indicate that the client is not receiving enough oxygen or that the pulse oximeter is not working properly.
The nurse should first check the sensor probe for any problems, such as poor attachment, nail polish, cold extremities, or motion artifact.
Repositioning the sensor probe may improve the accuracy of the reading and help the nurse determine the next course of action.
Choice B. Apply a cooling blanket to the client is wrong because a cooling blanket is used to lower the body temperature of a client with fever or hyperthermia.
It has no effect on the oxygen saturation level.
Choice C. Place the client in a side-lying position is wrong because a side-lying position may not improve the oxygenation of the client.
A more appropriate position would be a high Fowler’s position, which allows for maximum lung expansion and gas exchange.
Choice D. Ambulate the client is wrong because ambulating the client may worsen the oxygen saturation level if the client has a respiratory condition that causes hypoxemia.
The nurse should assess the client’s respiratory status and oxygen therapy before ambulating the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should remove the gloves first because they are the most contaminated piece of personal protective equipment (PPE) and should be discarded as soon as possible.
The nurse should then remove the gown, which may also be soiled with blood or body fluids, by grasping it at the neck and peeling it off inside out.
The mask and goggles should be removed last, by touching only the straps or earpieces, and avoiding touching the front of the mask or the lenses of the goggles.
Choice A is wrong because goggles are not the most contaminated piece of PPE and should be removed after the gown.
Choice B is wrong because gown is not the most contaminated piece of PPE and should be removed after the gloves.
Choice C is wrong because mask is not the most contaminated piece of PPE and should be removed after the gown and goggles.
Normal ranges for wound irrigation pressure are between 4 and 15 psi (pounds per square inch).
Higher pressures may damage the wound tissue and increase the risk of infection.
Lower pressures may not be effective in removing debris and bacteria from the wound.
Correct Answer is D
Explanation
Beneficence is the ethical principle of doing good and acting in the best interest of the patient. By administering pain medication prior to turning the client, the nurse is reducing the client’s suffering and promoting their well-being.
Choice A. Autonomy is wrong because autonomy is the ethical principle of respecting the patient’s right to self-determination and decision-making. The nurse is not asking for the client’s consent or preference before giving pain medication or turning them.
Choice B. Fidelity is wrong because fidelity is the ethical principle of being faithful and loyal to the patient and honoring one’s commitments and promises. The nurse is not demonstrating fidelity by giving pain medication or turning the client.
Choice C. Veracity is wrong because veracity is the ethical principle of telling the truth and being honest with the patient. The nurse is not providing any information or education to the client before giving pain medication or turning them.
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