A nurse is assessing a client's blood pressure using the two-step method. Which error could lead to inaccurate readings?

A. Advise the client to avoid discussing the deceased with others: Avoiding discussion can intensify feelings of isolation and prevent processing of grief. Healthy grieving involves expressing emotions and sharing memories rather than suppressing them.

B. Encourage the client to focus on other areas of life to distract themselves: Distraction may provide temporary relief but does not address the underlying complicated grief. Encouraging avoidance of emotions can delay healing and exacerbate distress.

C. Refer the client to a bereavement counselor or therapist: Complicated grief involves prolonged, intense, or impairing symptoms that interfere with functioning. Referral to a mental health professional provides specialized assessment, support, and therapy to help the client process grief safely and effectively.

D. Suggest participating in daily physical exercise routines for emotional management: Physical activity can improve mood and reduce stress but is an adjunctive strategy. It does not replace professional intervention for complicated grief, which may require targeted psychotherapy or counseling.

A. Reposition the client to improve airway clearance: Positioning can help optimize ventilation and drainage of secretions, but it does not immediately correct hypoxemia in a client with oxygen saturation of 88%.

B. Notify the provider of the low oxygen level: While communication with the provider is important, immediate action to improve oxygenation takes priority over notification. Delaying intervention could worsen hypoxemia.

C. Increase fluid intake to mobilize secretions: Adequate hydration helps thin secretions over time but is not an immediate intervention to address critically low oxygen saturation.

D. Administer oxygen via nasal cannula as prescribed: Providing supplemental oxygen is the priority intervention to raise oxygen saturation and prevent tissue hypoxia. Immediate oxygen delivery directly addresses the client’s critical hypoxemia and stabilizes their respiratory status.