A nurse is assessing a client's oxygen saturation level using a pulse oximeter. Which oxygen saturation level indicates the need for immediate intervention?

95%

92%

89%

86%

Answer and Explanation

The Correct Answer is D

Answer: d. 86%

Explanation: An oxygen saturation level of 86% indicates severe hypoxemia and requires immediate intervention to ensure adequate oxygenation.

a. Oxygen saturation levels of 95% are within the normal range and do not require immediate intervention.

b. Oxygen saturation levels of 92% are relatively low but may not require immediate intervention depending on the client's clinical condition.

c. Oxygen saturation levels of 89% indicate significant hypoxemia and require intervention, but immediate intervention is required at a level of 86%.

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Correct Answer is C

Explanation

Answer: c. Notify the healthcare provider of the significant difference.

Explanation: A significant difference in blood pressure readings between the right and left arms may indicate arterial occlusion or other circulatory abnormalities. The nurse should notify the healthcare provider for further evaluation and intervention.

a. Rechecking the blood pressure with a different cuff size may be appropriate if the initial readings were inaccurate, but it does not address the significant difference between the arms.

b. Documenting the finding is important, but further action is required to investigate the cause of the discrepancy.

d. Performing a Doppler ultrasound may be done as part of the diagnostic process to assess blood flow, but the healthcare provider should be notified first for appropriate evaluation.

A. Insert the thermometer into the rectum for accurate measurement. B. Place the thermometer in the client's axilla and secure with a towel. C. Swipe the thermometer gently across the client's forehead. D. Hold the thermometer under the client's tongue for 30 seconds.

Correct Answer is C

Explanation

Answer: c. Swipe the thermometer gently across the client's forehead.

Explanation: Temporal artery thermometers are used by swiping the thermometer gently across the client's forehead. The device measures the temperature of the temporal artery, which correlates with core body temperature.

a. Inserting the thermometer into the rectum is not the appropriate method for using a temporal artery thermometer.

b. Placing the thermometer in the axilla is appropriate for axillary temperature measurement but not for temporal artery thermometers.

d. Holding the thermometer under the tongue is appropriate for oral temperature measurement but not for temporal artery thermometers.

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A nurse is assessing a client's oxygen saturation level using a pulse oximeter. Which oxygen saturation level indicates the need for immediate intervention?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's blood pressure and finds a significant difference between the blood pressure readings in the client's right and left arms. What action should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing a client's body temperature using a temporal artery thermometer. How should the nurse use the temporal artery thermometer?

Correct Answer is C

Explanation

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