A nurse is assessing a client's pulse oximetry reading and notices that the waveform is irregular and inconsistent. What action should the nurse take?

Document the finding as a normal variation.

Reapply the pulse oximeter on a different finger.

Assess the client for signs of respiratory distress.

Notify the healthcare provider of the irregular waveform. Answer: b. Reapply the pulse oximeter on a different finger.

Answer and Explanation

The Correct Answer is B

indicate poor sensor placement or a faulty pulse oximeter. The nurse should reapply the pulse oximeter on a different finger to obtain an accurate reading.

a. An irregular waveform is not a normal variation and should be investigated further.

c. Assessing the client for signs of respiratory distress is important but may not directly address the irregular waveform.

d. Notifying the healthcare provider may be necessary if the issue persists after reapplying the pulse oximeter.

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Correct Answer is C

Explanation

Explanation: Heart rate reflects the number of times the heart beats per minute and is an essential vital sign in assessing cardiovascular function.

a. Respiratory rate measures the number of breaths per minute, not heartbeats.

b. Blood pressure is the force of blood against the walls of arteries and is measured in mmHg, not heartbeats per minute.

d. Oxygen saturation measures the percentage of hemoglobin that is saturated with oxygen, not heartbeats per minute.

A. Administer oxygen via a nasal cannula. B. Place the client in a supine position. C. Reassess the respiratory rate after 1 hour. D. Perform a thorough respiratory assessment.

Correct Answer is D

Explanation

Explanation: A respiratory rate of 8 breaths per minute is significantly below the normal range (12-20 breaths per minute), indicating potential respiratory distress. The nurse should perform a thorough respiratory assessment to gather more information and determine appropriate interventions.

a. Administering oxygen may be necessary, but the nurse should first assess the client's respiratory status before initiating any interventions.

b. Placing the client in a supine position is not indicated and may worsen respiratory distress in some situations.

c. Reassessing after 1 hour is not appropriate when a client is experiencing abnormal vital signs; immediate action is needed.

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A nurse is assessing a client's pulse oximetry reading and notices that the waveform is irregular and inconsistent. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's vital signs. Which vital sign reflects the number of times the heart beats per minute?

Correct Answer is C

Explanation

A nurse is assessing a client's respiratory rate and finds it to be 8 breaths per minute. What action should the nurse take first?

Correct Answer is D

Explanation

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A nurse is assessing a client's pulse oximetry reading and notices that the waveform is irregular and inconsistent. What action should the nurse take?