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 B

Explanation

. Assess your patient’s lower extremities and lungs for ﬂuid retention.

If a patient’s intake is 2500ml and her output is 1200ml from a catheter bag, and you are concerned that she may not be excreting enough urine for the amount of water she is taking in, the most appropriate next step would be to assess her lower extremities and lungs for ﬂuid retention. This can help determine if the patient is retaining water and if further intervention is necessary.

A. Inspiration B. Expiration C. Intake D. Chest

Correct Answer is A

Explanation

Deep breathing or "diaphragmatic breathing" is a technique used to prevent recurrent pneumonia and improve lung function. During deep breathing, the patient is instructed to inhale deeply, expanding their lung volume as much as possible. This process is called inspiration.

Expiration, on the other hand, is the process of exhaling or breathing out air from the lungs. Intake refers to the process of taking in air or breathing in, while chest is a part of the body where the lungs are located.

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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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Correct Answer is B

Explanation

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Correct Answer is A

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