The nurse observes that the client’s pulse oximetry is 89%. What is the priority nursing action?

Perform respiratory assessment.

Document hypoxemia.

Check the placement of the pulse oximeter.

Report pulse oximetry to the health care provider.

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is A

Explanation

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.

A. “Car seats are recommended until children are at least 10 years old/ B. “Your child will be safe in the car using the provided shoulder harness and lap belts/ C. "At the age of 6 your child should be using a booster seat.' D. "Car seats are only recommended until children are 3 years old."

Correct Answer is C

Explanation

Booster seats are recommended for children between the ages of 4 and 8, or until they are 4'9" tall. This is because seat belts are designed for adults and may not properly fit a child's smaller body. A booster seat helps to position the seat belt correctly on the child's body, improving the eﬀectiveness of the seat belt and reducing the risk of injury in the event of a crash.

Option a is incorrect because 10 years old is too old to need a car seat. Option b is incorrect because children under the age of 8, or under 4'9" tall, should not use a seat belt alone. Option d is incorrect because car seats are recommended until children are at least 4 years old, not 3.

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The nurse observes that the client’s pulse oximetry is 89%. What is the priority nursing action?

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Naxlex Comprehensive Predictor Exams

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