The nurse is obtaining a pulse oximetry reading for a client admited with exacerbation of chronic obstructive pulmonary disease (COPD). When observing a reading of 91%. what action should the nurse perform?
No action is required, because this may be normal for the client
The nurse should prepare intubation equipment for the health care provider
Administer oxygen at 6 L/m by nasal cannula
Have the client breath into a paper bag
The Correct Answer is A
A. This is the most appropriate response. Clients with COPD often have chronically elevated carbon dioxide levels, which can lead to a compensatory decrease in the oxygen saturation level. A reading of 91% may be within their normal range.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Pulse oximetry is a non-invasive method of monitoring the oxygen saturation level in the blood. A normal range for oxygen saturation is between 95% and 100%. An oxygen saturation level of 89% indicates hypoxemia, which is a serious condition that can lead to tissue damage, organ failure, and even death if left untreated.
Therefore, the priority nursing action is to perform a respiratory assessment to determine the cause of the hypoxemia. This should include assessing the client's airway patency, breathing patern, lung sounds, and oxygen therapy if the client is already receiving it. The nurse should also observe for any signs of respiratory distress such as cyanosis, accessory muscle use, or difficulty breathing.
While it is important to document hypoxemia and report it to the healthcare provider, the priority at this time is to assess and intervene promptly to prevent further deterioration of the client's condition. Checking the placement of the pulse oximeter may be necessary if the reading is unreliable, but it is not the priority in this scenario.
Correct Answer is D
Explanation
Atrial fibrillation is a common arrhythmia, and diuretics are often used in the management of patients with this condition to help control fluid balance. However, diuretics can cause electrolyte imbalances, especially hypokalaemia (low potassium levels), which can lead to muscle cramps and other complications.
A Complete Metabolic Panel (CMP) is a blood test that measures various electrolytes, glucose, and other important components. Among the options given, the most likely lab value to be abnormal in Patient MK's case is a low level of potassium (K+), which is consistent with her symptoms and diuretic use. Option d, K+ -
-
- mEq/L, is the correct option as it represents a low level of potassium, which is defined as a value less than 3.5 mEq/L.
Option a, Mg2 – 20 mEq/L, represents high magnesium levels, which are not typically associated with diuretic use or muscle cramps. Option b, Na+ - 123 mEq/L, represents low sodium levels, which are less likely to occur with diuretic use, and are typically associated with other conditions. Option c, Ca2 – 10.0 mg/dl, represents normal calcium levels and is not typically affected by diuretic use.
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