During assessment of a client on the respiratory unit, the pulse oximetry monitor indicates a drop of SpO2 from 98% to 87% over four hours in a client who previously had normal range oxygen saturation level. Which of the following actions should the nurse perform first?

Administer supplemental oxygen to the client.

Check the position of the pulse oximeter probe and ensure it is properly attached.

Assess the client's airway for obstruction.

Notify the healthcare provider immediately.

Answer and Explanation

The Correct Answer is B

A. Administering supplemental oxygen is appropriate if the low oxygen saturation is confirmed, but the nurse should first verify the accuracy of the reading to avoid unnecessary interventions.

B. Checking the position of the pulse oximeter probe and ensuring it is properly attached is the first step. Faulty probe placement or technical issues can cause inaccurate readings, so confirming the validity of the drop in SpO2 is essential before taking further action.

C. Assessing the client's airway for obstruction is critical if the low SpO2 is verified and no technical issues are found. However, this step follows confirming the accuracy of the pulse oximetry reading.

D. Notifying the healthcare provider is necessary if the drop in SpO2 is confirmed and persists despite initial nursing interventions, but it is not the first action.

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Correct Answer is C

Explanation

A. Buck's extension traction is not used to reduce fractures but to provide comfort, maintain alignment, and reduce muscle spasms in the affected area. Reduction of the fracture typically occurs through surgical intervention.

B. Buck's extension traction is not used to maintain the alignment of pins, as there are no pins involved in this type of traction. It is designed to relieve muscle spasms and provide comfort to the affected limb.

C. Buck's extension traction is primarily used to relieve muscle spasms and provide a steady pull on the affected limb to maintain alignment and reduce pain. This is particularly important in hip fractures to prevent further injury and discomfort.

D. Buck's extension traction does not allow for supported movement of the extremity; instead, it helps to immobilize the limb and reduce muscle spasms.

A. Active range-of-motion exercises of the left leg B. Log rolling every 2 hr C. Passive range of motion to the right leg D. Isometric exercises of both legs

Correct Answer is D

Explanation

A. Active range-of-motion exercises of the left leg promote mobility in the unaffected limb but do not fully address the need for maintaining muscle strength in both legs.

B. Log rolling every 2 hours is a technique used for clients who require spinal precautions or have limited movement due to back injuries. It does not promote mobility for a client in Buck's traction.

C. Passive range of motion to the right leg may prevent joint stiffness but does not actively maintain or improve muscle strength. Additionally, movement of the affected limb should be minimized to maintain the alignment of the traction.

D. Isometric exercises of both legs are appropriate for promoting mobility and maintaining muscle strength without disrupting the traction. These exercises involve contracting the muscles without moving the joints, which is safe for the affected limb in Buck's traction.

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During assessment of a client on the respiratory unit, the pulse oximetry monitor indicates a drop of SpO2 from 98% to 87% over four hours in a client who previously had normal range oxygen saturation level. Which of the following actions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching?

Correct Answer is C

Explanation

A nurse is caring for an adolescent client whose right leg is in Buck's traction. Which of the following interventions should the nurse implement to promote the client's mobility?

Correct Answer is D

Explanation

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