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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Paper mask and gown.
Choice A rationale:
The stethoscope is not typically placed in a biohazard bag. It is cleaned and disinfected after each use, especially when used with a patient with an infectious disease like MRSA.
Choice B rationale:
Bed linens are usually placed in a designated linen bag, not a biohazard bag, even when the patient has an infectious disease. The linens are then laundered according to the healthcare facility’s infection control guidelines.
Choice C rationale:
A sputum specimen is typically placed in a designated specimen container, not a biohazard bag. The container is then sent to the lab for analysis.
Choice D rationale:
The paper mask and gown used while caring for a patient with MRSA should be placed in a designated biohazard bag before being removed from the room. This is because these items may have come into contact with the bacteria and could potentially spread the infection.
Correct Answer is D
Explanation
Choice A reason: The nurse cannot force the client to take medication against their will, even if it is a controlled substance.
Choice B reason: Crediting the medication back and placing it in the client's medication box is not appropriate as the medication has already been removed from the unit dose wrapper.
Choice C reason: Keeping the medication to see if the client will want to take it later is not safe practice as it could lead to medication errors or misuse.
Choice D reason: The nurse should dispose of the medication properly, and having another nurse witness the disposal is a standard procedure to ensure that controlled substances are accounted for.
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