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 correct answer is choice A. Interlock her fingers and hold her hands away from her body above her waist.
This is because this position minimizes the risk of contaminating the sterile gloves by touching any non-sterile surfaces or objects.
The nurse should also keep her hands above her waistline to prevent contamination
Choice B is wrong because clasping the hands together behind the body at the waist could contaminate the gloves by touching the non-sterile gown or the skin
Choice C is wrong because placing one hand over the other against the part of the gown covering the upper body could contaminate the gloves by touching the non-sterile gown or the skin
Choice D is wrong because keeping the arms at the sides of the body with the hands in a relaxed position could contaminate the gloves by touching any nonsterile surfaces or objects
Sterile gloves are a type of disposable rubber gloves that are put through specific procedures to eliminate germs and microorganisms.
They are used to prevent and minimize infection during surgeries or invasive procedures
Correct Answer is D
Explanation
The correct answer is D. Using two gloved fingers to open the client’s mouth for cleaning.
Choice A rationale:
Lowering the side rail on the side of the bed where the AP will stand is necessary for safe access to the client. However, the AP should ensure the opposite side rail is up to prevent the client from falling.
Choice B rationale:
Using an oral care sponge swab moistened with cool water is an appropriate method for cleaning the mouth of an unconscious client. It helps maintain oral hygiene and comfort.
Choice C rationale:
Wearing clean gloves is essential for infection control and is a standard practice when performing mouth care to protect both the client and the caregiver.
Choice D rationale:
Using two gloved fingers to open the client’s mouth is not recommended as it can cause injury to the caregiver if the client bites down reflexively. Instead, a padded tongue blade should be used to gently open the mouth.
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