Share This Link

Document the current oxygen saturation: Documenting is important, but it is not the first action when the patient is hypoxemic - intervention to correct the low saturation should come first.

Call the respiratory therapist for an assessment: Useful if you need help or advanced adjustment, but calling RT delays the immediate intervention; first attempt simple measures (increase flow, reposition, confirm cannula placement) and then request RT if saturation does not improve.

Reassess the oxygen saturation in 30 minutes: Waiting 30 minutes without intervening is unsafe for a patient with SpO₂ 88%; reassessment should be immediate after interventions, not delayed.

The patient is relaxed and comfortable: Accessory muscle use contradicts relaxation - it indicates increased effort, not comfort.

The patient's oxygen saturation is likely to be above 95%: Accessory muscle use suggests inadequate ventilation/oxygenation risk, so high oxygen saturation is unlikely to be assumed; you must measure SpO₂ to know.

The patient needs immediate cardiopulmonary resuscitation: Accessory muscle use indicates distress but not arrest - CPR is for absent pulse/breathing, which is not implied here.

The patient's fever is likely due to dehydration: Dehydration can raise temperature slightly, but a postoperative temp of 39°C (102.2°F) is more consistent with infection or significant inflammatory response than simple dehydration.

The fever is a normal response to surgery: Mild temperature elevation can occur after surgery, but 39°C is higher than expected “normal” postoperative inflammatory response and warrants evaluation for infection or other causes.

The increased temperature is due to stress response: Stress/inflammatory responses after surgery can raise temperature modestly, but a high fever (39°C) should prompt consideration of infection rather than assuming only stress.

The need to inflate the cuff further: If you initially heard no sounds at all, you might need to inflate more; however the pattern “sound becomes muffled then disappears” describes the normal cuff deflation sequence and indicates diastolic pressure, not a need to inflate more.

The patient is experiencing a heart murmur: Heart murmurs alter heart sounds but do not cause the Korotkoff sound pattern of muffling and disappearance that defines diastolic pressure - muffling/disappearance is a cuff-related phenomenon.

The systolic pressure: Systolic pressure is recorded at the first appearance of Korotkoff sounds (the first tapping sound), not at muffling/disappearance.

Transfer board: A transfer board is useful for sliding a patient between two horizontal surfaces (e.g., bed to chair) when the patient can assist by sliding, but it is not ideal for moving a client onto a stretcher where surfaces may be at different heights or full-body support is needed.

Crutches: Crutches are an ambulation aid for walking, not an assistive device for moving a patient from a bed to a stretcher.

Gait belt: A gait belt helps with ambulation and short transfers when the patient can bear some weight, but it is not the safest primary device for sliding a patient onto a stretcher when more controlled lateral transfer (draw sheet) is required.

Immediately administer antihypertensive medication: Medication should not be given based on a single elevated reading without confirmation and assessment of symptoms, history, and provider orders.

Inform the patient that their blood pressure is normal: 150/95 mm Hg is above normal and should not be dismissed as normal.

Ask the patient to lie down and rest for 30 minutes before rechecking: Excessive delay - a brief rest (a few minutes) is appropriate before rechecking; asking for a 30-minute rest is not necessary as the immediate next step.

The patient is experiencing a normal side effect of the medication: Beta-blockers commonly cause decreased heart rate, but this answer is vague and does not identify the medication as the cause.

The patient's heart rate is likely unrelated to the medication: A new or low pulse after beta-blocker administration is most often related to the drug.

The patient's low pulse is due to dehydration: Dehydration typically causes tachycardia, not bradycardia, so this is an unlikely explanation.

The walker should be at the level of the patient's shoulders: A walker set at shoulder level is too high and causes poor posture; it should be adjusted to wrist or hip level so the patient's elbows are slightly flexed.

The patient should lean forward while walking: Leaning forward increases fall risk and is unsafe; the patient should stand upright with slight forward movement only when stepping, maintaining good posture.

The patient should use the walker to climb stairs: Standard walkers should not be used to climb stairs; stairs require specific techniques or additional assistance/assistive devices.