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 A
Explanation
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.
Correct Answer is B
Explanation
This means low sodium levels in the blood.
Sodium is an electrolyte that helps regulate fluid balance and nerve and muscle function.
Vomiting and diarrhea can cause dehydration and loss of sodium through fluids.
Normal sodium levels are between 135 to 145 millimole/Liter.
Choice A is wrong because hypermagnesemia means high magnesium levels in the blood.
Magnesium is another electrolyte that helps with nerve and muscle function, as well as blood pressure and blood sugar regulation.
Hypermagnesemia is rare and usually caused by kidney failure or excessive use of magnesium supplements or laxatives.
Normal magnesium levels are between 1.46 to 2.68 milligram/deciliter.
Choice C is wrong because hypocalcemia means low calcium levels in the blood.
Calcium is an electrolyte that helps with bone health, muscle contraction, blood clotting and nerve signaling.
Hypocalcemia can be caused by vitamin D deficiency, kidney disease, thyroid problems or certain medications.
Normal calcium levels are between 8.8 to 10.7 milligram/deciliter.
Choice D is wrong because hyperkalemia means high potassium levels in the blood.
Potassium is an electrolyte that helps with nerve and muscle function, especially the heart.
Hyperkalemia can be caused by kidney disease, diabetes, adrenal gland disorders or certain medications.
Normal potassium levels are between 3.6 to 5.5 millimole/Liter.
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