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.
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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Related Questions
Correct Answer is C
Explanation
CPR (Cardiopulmonary Resuscitation) is a life-saving procedure that is performed when a person's heart has stopped beating. It involves chest compressions and rescue breathing to restore the circulation of oxygenated blood to the brain and other vital organs. The timely initiation of CPR can significantly increase the chances of a patient's survival.
In a healthcare setting, UAPs/CNAs are often trained to provide basic life support, including initiating CPR, until a healthcare provider arrives. However, giving IV epinephrine, intubating the patient, and obtaining arterial blood gases are all advanced medical procedures that require specialized training and expertise. These actions should only be performed by trained healthcare providers, such as registered nurses, physicians, or respiratory therapists, and cannot be delegated to UAPs/CNAs.
Correct Answer is C
Explanation
Dehydration can cause a decrease in blood volume, leading to a drop in blood pressure (hypotension) and an increase in heart rate (tachycardia) as the body tries to compensate. Tenting skin and dry mucous membranes are also signs of dehydration, but wet mucous membranes are not. Crackles in the lungs, edema, and confusion can occur with fluid overload, but not with dehydration.
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