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

Before pumping the medication into the chamber, you should educate the patient to exhale. This means that the patient should breathe out fully before using the inhaler. This helps to empty the lungs of air and create more space for the medication to be inhaled.

A. Three B. One C. Four D. Two

Correct Answer is B

Explanation

Choice A reason: This is incorrect because it shows that the PN is not familiar with the nursing diagnosis criteria. Three defining characteristics are not the least number required for the diagnosis of Impaired Verbal Communication.

Choice B reason: This is correct because it shows that the PN is familiar with the nursing diagnosis criteria. One defining characteristic is the least number required for the diagnosis of Impaired Verbal Communication, according to the NANDA-I taxonomy.

Choice C reason: This is incorrect because it shows that the PN is not familiar with the nursing diagnosis criteria. Four defining characteristics are not the least number required for the diagnosis of Impaired Verbal Communication.

Choice D reason: This is incorrect because it shows that the PN is not familiar with the nursing diagnosis criteria. Two defining characteristics are not the least number required for the diagnosis of Impaired Verbal Communication.

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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

Correct Answer is A

Explanation

The Practical Nurse (PN) assessing a client for the nursing diagnosis of Impaired Verbal Communication is aware that the least number of defining characteristics for this diagnosis is:

Correct Answer is B

Explanation

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