A nurse caring for a child who is receiving oxygen therapy and is on a continuous oxygen saturation monitor that is reading 89%. Which of the following actions should the nurse take first?
Place the child in the Fowler's position.
Ensure proper placement of the sensor probe.
Increase the oxygen flow rate.
Encourage the child to take deep breaths.
The Correct Answer is B
Choice A reason: While the Fowler's position can aid in breathing, it is not the first action to take if the oxygen saturation monitor is reading low.
Choice B reason: Ensuring the proper placement of the sensor probe is the first step, as incorrect placement can lead to inaccurate readings.
Choice C reason: Increasing the oxygen flow rate should only be considered after confirming the accuracy of the oxygen saturation reading.
Choice D reason: Encouraging deep breaths may be helpful, but it is not the first action to take. The priority is to ensure the oxygen saturation reading is accurate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: Dornase alfa is used to break down mucus and is beneficial for children with cystic fibrosis, not typically prescribed for asthma.
Choice B reason: Placing a child in an upright position can help ease breathing during an asthma attack by reducing pressure on the diaphragm.
Choice C reason: Bronchodilators are medications that help open the airways and are a mainstay in the treatment of asthma.
Choice D reason: Chest percussion can help loosen mucus in the lungs; however, it is not commonly used in the routine management of asthma.
Choice E reason: Monitoring oxygen saturation is crucial in assessing the severity of an asthma attack and determining the effectiveness of treatment.
Correct Answer is B
Explanation
Choice A reason: While administering vitamins and minerals is important, it does not provide complete nutrition, especially for a client with such extensive burns and absent bowel sounds.
Choice B reason: This is the correct choice because total parenteral nutrition (TPN) provides complete nutrition intravenously, bypassing the gastrointestinal tract, which is necessary when bowel sounds are absent, indicating a non-functioning GI system.
Choice C reason: Enteral feedings require a functioning GI tract. With absent bowel sounds, this indicates a high risk for complications like aspiration or feeding intolerance.
Choice D reason: Encouraging oral intake is not feasible for a client with extensive burns and absent bowel sounds due to the high risk of inadequate intake and aspiration.
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