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?

Complete the intermittent suction of the nasopharynx.

Apply an oxygen mask over the client's nose and mouth.

Reposition the pulse oximeter clip to obtain a new reading.

Stop suctioning until the pulse oximeter reading is above 95%.

Answer and Explanation

The Correct Answer is A

Choice A reason: If the oxygen saturation remains stable during the procedure, it indicates that the suctioning is not adversely affecting the client's oxygenation, and the nurse can safely continue.

Choice B reason: Applying an oxygen mask is not necessary if the oxygen saturation is stable and within a safe range.

Choice C reason: Repositioning the pulse oximeter clip is only necessary if there is a concern about the accuracy of the reading, not when the reading is stable.

Choice D reason: There is no need to stop suctioning if the oxygen saturation is stable at 94%, as this is within the acceptable range for most clients.

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Correct Answer is C

Explanation

Choice A reason: This response is inappropriate and dismissive of the sibling's concern and the client's need for communication assistance.

Choice B reason: Providing medical information to someone who is not an approved interpreter could breach confidentiality and privacy regulations.

Choice C reason: It is important to use an approved interpreter to ensure accurate and confidential communication of medical information.

Choice D reason: While the healthcare provider will share information, it is essential to use an approved interpreter to facilitate understanding and maintain confidentiality.

A. Offer to contact the family's spiritual counselor to meet with the client and spouse. B. Discuss comfort measures with the client and family that will be available during withdrawal. C. Inform the healthcare provider of the client's desire to have life support withdrawn. D. Explain the actions that the healthcare team will follow for the removal of life support.

Correct Answer is C

Explanation

Choice A reason: Offering to contact the family's spiritual counselor can provide emotional and spiritual support, but it is not the immediate priority in a situation where the client has expressed a desire to have life support withdrawn.

Choice B reason: Discussing comfort measures is important for the client and family to understand what to expect during the withdrawal process. However, this step comes after the healthcare provider has been informed and a plan of care is being developed.

Choice C reason: Informing the healthcare provider is the priority nursing intervention. The nurse acts as an advocate for the client's wishes and ensures that the appropriate steps are taken to respect the client's autonomy and decisions regarding their care.

Choice D reason: Explaining the actions that the healthcare team will follow is an essential part of the process, but it is not the first step. The healthcare provider must first be informed so that the proper orders and arrangements can be made.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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