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 correct answer is choice D. A living will can specify which medical procedures a person wants or does not want to receive in certain situations, such as when they are terminally ill or permanently unconscious.
A living will is a type of advance directive, which is a legal document that provides instructions for medical care if a person is unable to make decisions for themselves.
Choice A is wrong because a person does not need to have advance directives in order to refuse recommended treatment.
They have the right to accept or decline any medical intervention at any time, as long as they are competent and able to communicate their wishes.
Choice B is wrong because a person does not need an attorney to name a designee in their health care proxy.
A health care proxy is another type of advance directive that appoints a person to make health care decisions for someone else if they are unable to do so.
A health care proxy can be completed without involving a lawyer, as long as it meets the state’s requirements for a valid document.
Choice C is wrong because a living will cannot be an oral statement that a person agrees upon with their provider.
A living will must be in writing and follow the state’s laws for creating legal documents.
Depending on the state, a living will may need to be signed by a witness or notarized.
Correct Answer is A
Explanation
The correct answer is choice A: "I will speak with your provider on your behalf."
Choice A rationale: The principle of advocacy in nursing involves supporting and speaking up for clients to ensure their rights, needs, and preferences are respected. By offering to speak with the provider on the client's behalf, the nurse demonstrates advocacy by actively working to represent the client's interests and facilitate communication between the client and the health care team.
Choice B rationale: While promising to fulfill commitments is an aspect of maintaining professional integrity, it does not directly demonstrate advocacy. Advocacy is more about actively supporting the client's rights and needs rather than personal dedication to fulfilling promises.
Choice C rationale: Maintaining the privacy and confidentiality of client information is essential in nursing practice, but it is not specifically related to advocacy. Privacy is a separate ethical principle that focuses on protecting the client's personal information and upholding their right to privacy.
Choice D rationale: Encouraging clients to make decisions about their health care is important for promoting autonomy. However, advocacy involves actively supporting the client's decisions and ensuring their rights are respected, rather than simply allowing them to make decisions.
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