A nurse is caring for a child that is receiving oxygen therapy and is on a continuous oxygen saturation monitor that is reading 89%. Which of the following actions should the nurse take first?

Encourage the child to take deep breaths.

Ensure proper placement of the sensor probe.

Place the child in the Fowler's position.

Increase the oxygen flow rate.

Answer and Explanation

The Correct Answer is B

A. Encourage the child to take deep breaths: While deep breaths may help improve oxygenation, the first action should be confirming that the monitoring device is correctly placed and providing accurate readings.

B. Ensure proper placement of the sensor probe: Incorrect placement of the sensor probe (e.g., on a fingernail or a cold extremity) can lead to inaccurate oxygen saturation readings. Ensuring proper placement is the priority to verify the accuracy of the reading.

C. Place the child in the Fowler's position: Fowler's position can help with breathing, but before making this change, the nurse should first verify that the pulse oximeter is working correctly.

D. Increase the oxygen flow rate: Increasing the oxygen flow rate may be necessary if the child’s oxygen saturation remains low, but the first step is to ensure the monitoring device is accurate.

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Correct Answer is B

Explanation

A. Cyanosis with crying: Cyanosis is typically seen in cyanotic heart defects, not in PDA, which is acyanotic.

B. Machine-like murmur: Characteristic of PDA due to continuous blood flow between the aorta and pulmonary artery.

C. Chronic hypoxemia: PDA usually leads to left-to-right shunting, not hypoxemia.

D. Weak pulses: Pulses are typically bounding due to increased blood flow, not weak.

A. Medium formed stool with an orange tint B. Liquid stool C. Small, round pellet shaped stool D. Large, bulky, frothy, greasy, and foul-smelling stool (steatorrhea)

Correct Answer is D

Explanation

A. Medium formed stool with an orange tint: Not typical in cystic fibrosis.

B. Liquid stool: While diarrhea can occur, it is not the hallmark of cystic fibrosis-related malabsorption.

C. Small, round pellet-shaped stool: More indicative of constipation, not cystic fibrosis.

D. Large, bulky, frothy, greasy, and foul-smelling stool (steatorrhea): Characteristic of malabsorption caused by pancreatic enzyme insufficiency in cystic fibrosis.

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A nurse is caring for a child that is receiving oxygen therapy and is on a continuous oxygen saturation monitor that is reading 89%. Which of the following actions should the nurse take first?

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