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 C

Explanation

A. Placing the crib in front of the window can pose a risk of injury if the infant gains access to the window blinds or falls out of the window.
B. Hanging toys across the crib rails can pose a risk of strangulation or choking if the infant becomes entangled in them.
C. Keeping the door to the bathroom closed prevents the infant from accessing potentially hazardous items such as medications, cleaning products, or small objects that may pose a choking hazard.
D. Setting the hot water heater at 140 degrees Fahrenheit increases the risk of scald burns for the infant. The water temperature should be set at or below 120 degrees Fahrenheit to prevent burns.

A. Frequently remind the client of the expectations for her behavior. B. Encourage the client to participate in a group activity in the dayroom. C. Allow the client to pick her own choice of clothing. D. Encourage the client to increase physical activity during the day.

Correct Answer is B

Explanation

A. Frequently reminding the client of behavioral expectations may agitate or escalate the client further, as individuals experiencing mania may already have difficulty with impulse control and irritability.

B. Encouraging the client to participate in a group activity can help redirect excess energy and provide a structured outlet for social interaction. Group activities can also help decrease isolation and provide opportunities for the client to engage in appropriate behaviors.
C. Allowing the client to pick her own clothing is generally appropriate and promotes autonomy, but it may not directly address the symptoms of mania.
D. While physical activity can be beneficial for individuals with bipolar disorder, encouraging increased physical activity during a manic episode may exacerbate symptoms or lead to overexertion.

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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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