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: Drawing up regular insulin before NPH is the correct technique, as regular insulin is short-acting and NPH is intermediate-acting. Mixing insulins should be done in a specific order to prevent contamination or altering the action of the insulins.
B: Seeing a primary care provider for foot care is appropriate for a person with diabetes. Foot care is essential due to the high risk of foot problems in diabetes, and a primary care provider can offer appropriate treatment and guidance.
C: Treating hypoglycemic reactions with 15 g of carbohydrates is the recommended initial treatment. This quick-acting source of sugar helps to raise blood glucose levels efficiently during a hypoglycemic episode.
D: Listing sweating, shaking, and palpitations as symptoms is incorrect for hyperglycemia; these are symptoms of hypoglycemia. Hyperglycemia symptoms include frequent urination, increased thirst, and blurred vision. This indicates a lack of understanding of the difference between hyperglycemia and hypoglycemia, which is crucial for managing diabetes.

A. Nitrites negative B. Ketones positive C. Uric acid 475 mg/24 hr D. Specific gravity 1.020

Correct Answer is B

Explanation

A. Nitrites negative is a normal finding and does not typically require notification of the provider. Nitrites are usually present in the urine when there is a urinary tract infection.
B. Ketones positive in the urine can indicate diabetic ketoacidosis (DKA), which is a serious condition requiring prompt medical attention. Therefore, the nurse should notify the provider about this result.
C. Uric acid levels can be elevated in conditions such as gout or kidney disease, but the specific value provided is within the normal reference range for a 24-hour urine collection. Therefore, it does not warrant immediate notification.
D. Specific gravity of 1.020 is within the normal range (typically 1.005 to 1.030) and does not usually require notification of the provider.

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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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