A nurse has obtained a client's oxygen saturation measurement of 88% on 2 liters of oxygen via nasal cannula. Which of the following actions should the nurse take?

Check the client's heart rate on the oximeter.

Compare the result with the baseline reading.

Decrease the amount of oxygen administered.

Perform another reading while the client ambulates.

Answer and Explanation

The Correct Answer is B

A. Checking the client’s heart rate on the oximeter may provide additional data but does not address the low oxygen saturation or guide immediate intervention.
B. Comparing the result with the baseline reading helps determine if the 88% saturation is a sudden drop or consistent with the client’s usual oxygenation status, guiding further actions.
C. Decreasing the amount of oxygen would be inappropriate, as the client is already experiencing low oxygen saturation. Increasing oxygen may be necessary based on provider orders.
D. Performing another reading while the client ambulates could further decrease oxygen levels and is not an appropriate immediate action. Oxygenation should be assessed at rest before considering exertion.

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Correct Answer is D

Explanation

A. Incorrect. Pinching the infant's nares can cause distress and may not effectively prevent aspiration.
B. Incorrect. Administering the whole dose at once increases the risk of the infant choking or aspirating the medication.
C. Incorrect. Holding the infant in a side-lying position may not effectively prevent aspiration and may increase the risk of choking.
D. Correct. Administering the medication using a needleless syringe in the buccal cavity allows for slow and controlled administration, reducing the risk of aspiration. This method also minimizes the chance of the infant gagging or spitting out the medication.

A. 2+ deep tendon reflex. B. Facial flushing. C. Respiratory rate 13/min. D. Urine output 20 mL/hr.

Correct Answer is D

Explanation

A. 2+ deep tendon reflexes are within the expected range and are not typically concerning in a client receiving magnesium sulfate for preeclampsia.
B. Facial flushing can occur as a side effect of magnesium sulfate but is not typically a cause for immediate concern unless it is severe or accompanied by other symptoms.
C. A respiratory rate of 13/min is within the expected range and is not typically a concerning finding in a client receiving magnesium sulfate.
D. Urine output of 20 mL/hr is significantly decreased and may indicate reduced renal perfusion, which can be a serious complication of preeclampsia. Therefore, it should be reported to the provider for further evaluation and management.

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A nurse has obtained a client's oxygen saturation measurement of 88% on 2 liters of oxygen via nasal cannula. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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