The nurse receives a new prescription to administer oxygen at 3 L/minute via nasal cannula to maintain an oxygen saturation between 90 and 100% for a client. The nurse obtains an oxygen saturation reading of 85%, and after repositioning the oximeter on a different finger, obtains a second reading of 87%. Which action should the nurse take next?

Place the client in a Trendelenburg position.

Securely place the prongs of the cannula in the nostrils.

Place the pulse oximeter on the client's earlobe.

Document the second reading in the client's record.

Answer and Explanation

The Correct Answer is B

Choice A reason: The Trendelenburg position is not indicated for increasing oxygen saturation and could be harmful, especially for clients with respiratory distress.

Choice B reason: Ensuring that the prongs of the nasal cannula are securely placed in the nostrils is important for effective oxygen delivery, especially if the oxygen saturation remains below the prescribed range.

Choice C reason: Placing the pulse oximeter on the client's earlobe is an alternative site for obtaining a saturation reading, but it does not address the issue of potentially inadequate oxygen delivery.

Choice D reason: While documentation is important, the nurse must first address the low oxygen saturation levels before documenting the readings.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Offering comfort that healing can happen at any point in time may not be appropriate for a client in the terminal stage of lung cancer, as it may give false hope.

Choice B reason: Offering strategies to provide comfort to the client can be helpful, but it does not address the spouse's immediate emotional needs.

Choice C reason: Suggesting that the spouse go home to sleep may seem dismissive of the spouse's current emotional state and need for support.

Choice D reason: Explaining that the staff will strive to keep the client comfortable addresses the spouse's concern for the client's well-being and provides reassurance about the care being provided.

A. Serum potassium: 3.5 mEq/L (3.5 mmol/L), serum sodium: 142 mEq/L (142 mmol/L) B. Serum potassium: 4.5 mEq/L (4.5 mmol/L), serum sodium: 140 mEq/L (140 mmol/L) C. Serum potassium: 5.0 mEq/L (5.0 mmol/L), serum sodium: 138 mEq/L (138 mmol/L) D. Serum potassium: 3.0 mEq/L (3.0 mmol/L), serum sodium: 149 mEq/L (149 mmol/L)

Correct Answer is A

Explanation

Choice A reason: The results are within the normal reference range for both potassium and sodium, which is expected unless the client's condition has led to significant electrolyte imbalances.

Choice B reason: A serum potassium level of 4.5 mEq/L is at the higher end of the normal range, which might not be expected in a client with vomiting and diarrhea, conditions that often lead to lower potassium levels.

Choice C reason: A serum potassium level of 5.0 mEq/L is at the upper limit of the normal range and could indicate hyperkalemia, especially in the context of severe dehydration.

Choice D reason: A serum sodium level of 149 mEq/L is slightly above the normal range and could indicate hypernatremia, which may occur in dehydration but would require further assessment and intervention.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is in the terminal stage of lung cancer. Outside the room, the client's spouse expresses to the nurse feelings of helplessness and a lack of hope for the future. How should the nurse respond?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?

The nurse receives a report that a patient with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?

While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?

The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize that the client is at greater risk for the development of which complication?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?