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 C
Explanation
The correct answer is choice C. “Dangle your legs over the side of the bed.” This helps prevent orthostatic hypotension, which is a form of low blood pressure that happens when standing after sitting or lying down.
Dangling the legs over the side of the bed allows blood to flow back to the heart and increases blood pressure before standing up.
Choice A is wrong because “Perform regular isometric exercises.” Isometric exercises are muscle contractions without movement, such as squeezing a ball or clenching a fist.
These exercises do not help with orthostatic hypotension because they do not improve blood circulation or blood pressure.
Choice B is wrong because “Increase your intake of protein.” Protein intake does not affect orthostatic hypotension directly.
However, staying hydrated by drinking plenty of fluids can help prevent or manage the condition by maintaining blood volume and blood pressure.
Choice D is wrong because “Use your incentive spirometer.” An incentive spirometer is a device that helps improve lung function after surgery by encouraging deep breathing.
It does not prevent orthostatic hypotension because it does not affect blood pressure or blood flow.
Correct Answer is C
Explanation
According to the CDC1, chlorine bleach is an effective disinfectant for killing C. difficile spores on environmental surfaces.
It should be used in a 1:10 dilution of household bleach and water, freshly mixed daily.
Chlorine bleach can also kill other pathogens that may be present in the room of a client with C. difficile infection.
Choice A is wrong because chlorhexidine is not effective against C. difficile spores.
Chlorhexidine is an antiseptic that can be used for hand hygiene and surgical asepsis, but it does not kill spores.
Choice B is wrong because isopropyl alcohol is also not effective against C. difficile spores.
Alcohol-based hand sanitizers are not sufficient for preventing the spread of C. difficile, and soap and water should be used instead.
Choice D is wrong because triclosan is a type of antibacterial agent that is commonly found in some consumer products, such as soap and toothpaste. However, triclosan has no activity against C. difficile spores.
Triclosan may also contribute to antibiotic resistance and has potential adverse effects on human health and the environment.
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