A nurse is caring for a 58-year-old client who has a low oxygen saturation. The nurse is reviewing the client's data to create a plan of care. Complete the diagram by drawing arrows to connect the condition and two parameters the nurse should monitor to assess the client's progress.
Low oxygen saturation -> Respiratory rate and heart rate
Low oxygen saturation -> Blood pressure and temperature
Low oxygen saturation -> Lung sounds and chest expansion
Low oxygen saturation -> Hemoglobin and hematocrit
The Correct Answer is C
Choice A reason: Respiratory rate and heart rate are not specific indicators of oxygen saturation. They can be affected by many other factors, such as pain, anxiety, or dehydration.
Choice B reason: Blood pressure and temperature are not directly related to oxygen saturation. They can be influenced by other conditions, such as infection, inflammation, or shock.
Choice C reason: Lung sounds and chest expansion are relevant parameters to monitor for a client with low oxygen saturation. They can indicate the presence of respiratory problems, such as pneumonia, asthma, or atelectasis, that can impair gas exchange and oxygen delivery.
Choice D reason: Hemoglobin and hematocrit are measures of red blood cell count and volume. They can affect the oxygen-carrying capacity of the blood, but they are not directly affected by oxygen saturation. They can be altered by other factors, such as bleeding, dehydration, or anemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Tachycardia is a possible adverse effect of theophylline, as it is a methylxanthine that stimulates the central nervous system and the cardiac muscle. The nurse should instruct the client to monitor their pulse rate and report any palpitations, chest pain, or irregular heartbeat.

Choice B reason: Drowsiness is not a likely adverse effect of theophylline, as it is a stimulant that increases alertness and energy. The nurse should caution the client to avoid taking the medication close to bedtime, as it may cause insomnia.
Choice C reason: Constipation is not a common adverse effect of theophylline, as it does not affect the gastrointestinal motility or secretion. The nurse should advise the client to maintain a balanced diet, adequate fluid intake, and regular exercise to prevent constipation.
Choice D reason: Oliguria is not a typical adverse effect of theophylline, as it does not impair the renal function or cause fluid retention. The nurse should encourage the client to drink enough fluids to prevent dehydration and maintain a normal urine output.
Correct Answer is D
Explanation
Choice A reason: This is incorrect because reporting symptoms that last longer than 2 days is not specific to guaifenesin. This is a general instruction for any patient with a sinus infection, regardless of the medication they are taking.
Choice B reason: This is incorrect because reporting clear-colored sputum to the prescriber is not necessary. Clear-colored sputum indicates that the infection is improving and the mucus is thinning. This is a desired effect of guaifenesin, not a problem that needs to be reported.
Choice C reason: This is incorrect because guaifenesin does not have sedating effects. Guaifenesin is an expectorant that helps to break up and expel mucus from the respiratory tract. It does not cause drowsiness or impair the ability to drive or operate machinery.
Choice D reason: This is correct because increasing fluid intake is an important instruction for a patient taking guaifenesin. Fluids help to hydrate the body and thin the mucus, making it easier to cough up and clear the sinuses. Fluids also help to prevent dehydration and dryness of the mucous membranes.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
