A client's oxygen saturation is measured at 90% on room air. What action should the nurse take first?

Place the client in a prone position to improve oxygenation

Notify the provider and prepare for intubation

Increase oxygen via nasal cannula to 2 L/min.

Verify the reading and assess for signs of respiratory distress.

Answer and Explanation

The Correct Answer is D

A. Place the client in a prone position to improve oxygenation: Prone positioning may improve oxygenation in certain critically ill patients, but it is not the first step for a client with an SpO₂ of 90%. Immediate assessment is necessary before changing position.

B. Notify the provider and prepare for intubation: While persistent hypoxemia may eventually require provider notification, intubation is not indicated without assessment of the patient’s overall respiratory status. Premature escalation can lead to unnecessary interventions.

C. Increase oxygen via nasal cannula to 2 L/min: Administering supplemental oxygen may be appropriate, but initiating treatment without assessing for accuracy of the reading and current signs of respiratory distress could mask underlying issues or result in improper dosing.

D. Verify the reading and assess for signs of respiratory distress: The priority action is to confirm the SpO₂ measurement and evaluate for signs of hypoxia, such as increased work of breathing, cyanosis, or altered mental status. Assessment guides safe, evidence-based interventions and ensures accurate clinical decision-making.

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Correct Answer is A

Explanation

A. A patient presents with sudden onset facial drooping and slurred speech: Charting by Exception focuses on documenting deviations from normal findings. Sudden facial drooping and slurred speech are abnormal and potentially indicative of a stroke or other urgent condition, requiring detailed documentation and prompt provider notification.

B. A patient reports no pain and demonstrates normal gait: Normal findings are considered expected and typically do not require additional documentation in a CBE system unless they change from baseline.

C. A patient has a blood pressure of 120/80 mmHg with no other changes: This is within normal limits and would not require additional notes, as CBE emphasizes abnormal or significant deviations.

D. A patient exhibits stable vital signs and no new symptoms: Stability and absence of symptoms reflect expected outcomes and are usually captured by the standard flow sheet in CBE, requiring no extra documentation.

A. Following the pathway strictly, regardless of patient changes B. Adjusting the care plan when a patient's condition deteriorates unexpectedly C. Documenting a pathway deviation only if it improves the patient's condition. D. Using the critical pathway as a rigid schedule for patient interventions.

Correct Answer is B

Explanation

A. Following the pathway strictly, regardless of patient changes: Strict adherence without considering the patient’s evolving condition can compromise safety and individualized care. Critical pathways are guides, not rigid protocols.

B. Adjusting the care plan when a patient's condition deteriorates unexpectedly: Deviating from a critical pathway is appropriate when a patient’s clinical status changes. The nurse must use clinical judgment to modify interventions to meet the patient’s immediate needs while documenting and communicating the changes.

C. Documenting a pathway deviation only if it improves the patient's condition: All deviations, whether positive or negative, must be documented to maintain accountability, track outcomes, and inform future care planning. Selective documentation is not appropriate.

D. Using the critical pathway as a rigid schedule for patient interventions: Treating the pathway as a fixed schedule ignores patient variability. Effective use of critical pathways involves flexibility and adaptation based on individual patient responses.

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A client's oxygen saturation is measured at 90% on room air. What action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In a Charting by Exception (CBE) system, which scenario requires additional documentation?

Correct Answer is A

Explanation

A nurse is working in a healthcare facility that uses critical pathways to manage patient care. Which action by the nurse demonstrates an understanding of when to deviate from the critical pathway?

Correct Answer is B

Explanation

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