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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Use a filter needle to aspirate the medication.
This is because a filter needle can prevent glass particles from being drawn into the syringe when aspirating medication from an ampule.
Glass particles can cause harm to the patient if injected.
Choice A is wrong because cleansing the tip of the ampule with an alcohol swab after opening is not necessary and may contaminate the medication.
Choice B is wrong because adding 0.5 mL of diluent to the medication may alter the concentration and dosage of the medication.
Choice D is wrong because injecting air into the ampule prior to drawing the medication into a syringe is not required and may create pressure that can cause the ampule to break.
Correct Answer is B
Explanation
The correct answer is choice B. Devout practitioners of Islam prefer to have their heads turned toward Mecca at death.
This is because Mecca is considered the holiest city in Islam and facing it is a sign of respect and devotion.
Choice A is wrong because devout practitioners of Buddhism prefer to be cremated rather than buried.
Cremation is seen as a way of releasing the soul from the body and preparing for rebirth.
Choice C is wrong because devout practitioners of Judaism prefer to be buried as soon as possible after death, usually within 24 hours.
This is based on the biblical commandment to bury the dead quickly and respect their dignity.
Choice D is wrong because devout practitioners of Hinduism prefer to be cremated after death and not buried.
Cremation is believed to help the soul detach from the body and achieve liberation.
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