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 A

Explanation

A. An elevated serum calcium level (hypercalcemia) can indicate a complication of total parenteral nutrition, such as hypercalcemia resulting from excess calcium supplementation in the
TPN solution, which can lead to complications such as renal calculi and cardiac dysrhythmias.
B. The blood urea nitrogen (BUN) level within the normal range does not indicate a complication related to total parenteral nutrition.
C. The serum potassium level within the normal range does not indicate a complication related to total parenteral nutrition.
D. A normal white blood cell (WBC) count does not indicate a complication related to total parenteral nutrition.

A. The client's foot feels cooler than in the previous assessment. B. The client's pedal pulse in the right foot is not palpable. C. The client's capillary refill time is 5 seconds in the toes. D. The client reports a pain level of 8 on a scale from 3 to 10.

Correct Answer is B

Explanation

A. The client's foot feels cooler than in the previous assessment: While decreased temperature can indicate decreased perfusion, the absence of a palpable pedal pulse is a more concerning finding.
B. The client's pedal pulse in the right foot is not palpable: This finding suggests compromised blood flow distal to the site of the bypass graft, which could indicate graft occlusion or impaired circulation.
C. The client's capillary refill time is 5 seconds in the toes: While prolonged capillary refill time can indicate impaired circulation, the absence of a palpable pedal pulse is a more concerning finding.
D. The client reports a pain level of 8 on a scale from 3 to 10: Pain is subjective and can be managed with analgesics, but the absence of a palpable pedal pulse indicates a more serious issue related to perfusion.

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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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