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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Tachycardia is not typically associated with opioid intoxication. Instead, bradycardia or normal heart rate may occur due to the depressant effects of opioids on the central nervous system.
B. Opioid intoxication often results in decreased mental alertness, leading to symptoms such as drowsiness, confusion, or even unconsciousness.
C. Hyperreflexia, or exaggerated reflexes, is not a common manifestation of opioid intoxication. Instead, hyporeflexia or depressed reflexes may occur due to the central nervous system depression caused by opioids.
D. Pinpoint pupils are a classic sign of opioid intoxication. Opioids bind to receptors in the brainstem, causing pupillary constriction. This effect is so characteristic that pinpoint pupils are often referred to as "opioid pupils."
Correct Answer is B
Explanation
A. Instructing the client to report the theft to the police might be appropriate in cases of theft, but the nurse's primary responsibility is to ensure the safety and well-being of the client. Reporting
to the authorities can be pursued after ensuring the client's immediate safety.
B. Reporting the possible abuse to adult protective services is the appropriate action when financial exploitation or abuse is suspected. Adult protective services can investigate the situation and provide support and resources to ensure the client's safety.
C. Asking the client if there is another family member they can call for financial help is a valid consideration, but it does not address the potential abuse or exploitation of the client's finances.
D. Restricting visitation for the client's family until discharge is not appropriate without further assessment and intervention. It may also isolate the client from potential sources of support and assistance.
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