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
Answer: B. Compare the result with the baseline reading
Rationale:
A. Check the client's heart rate on the oximeter:
Although checking the heart rate may provide context for assessing the client's overall status, it does not address the primary concern of the low oxygen saturation. Understanding the client's baseline saturation level takes priority to guide further actions effectively.
B. Compare the result with the baseline reading:
Comparing the reading with the client's baseline is essential. For clients with chronic respiratory conditions, baseline oxygen levels may naturally be lower. Identifying if this 88% saturation is typical or unusual for the client helps determine the need for further intervention or adjustment.
C. Decrease the amount of oxygen administered:
Reducing oxygen flow when the saturation is low is contraindicated, as it could worsen hypoxia. Instead, increasing oxygen may be warranted if the reading remains below the baseline after further assessment.
D. Perform another reading while the client ambulates:
Repeating the reading during ambulation may worsen hypoxia and is not ideal without understanding baseline oxygenation at rest. Re-evaluation at rest or in a different position may be more appropriate for accurate assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should expect to find hyperkalemia in the medical record of a client who has sustained a full- thickness burn and is in the emergent phase of the burn. This is due to the release of potassium from damaged cells into the bloodstream.
a) Hypernatremia is not a common finding in the emergent phase of a burn.
b) Hypercalcemia is not a common finding in the emergent phase of a burn.
c) Hypermagnesemia is not a common finding in the emergent phase of a burn.
Correct Answer is B
Explanation
Kosher dietary laws, as observed in Judaism, have specific dietary restrictions. One of the primary restrictions is the prohibition of consuming shellfish and pork. Shrimp and clam chowder, which are made from shellfish, and the pulled-pork sandwich, which contains pork, are not suitable options for a kosher diet.
Roasted salmon, on the other hand, is an appropriate choice. Fish that have both fins and scales, such as salmon, are considered kosher and can be included in a kosher diet.
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