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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Bradycardia is an early indicator of a pneumothorax.": Bradycardia is not an early indicator of a pneumothorax. Common signs of pneumothorax in cystic fibrosis include sudden chest pain, difficulty breathing, and decreased breath sounds, not bradycardia.
B. "Administer a bronchodilator to the child after chest percussion therapy.": Chest percussion helps loosen secretions, and bronchodilators should be administered after the therapy to help open the airways and allow the mucus to be cleared more effectively.
C. "Engage the child in daily aerobic exercise.": While exercise is beneficial for children with cystic fibrosis, it should be tailored to the child's physical condition. Aerobic exercise might not be suitable for all children with CF, especially during exacerbations or respiratory distress.
D. "A pigeon-shaped chest might become evident as the disease progresses.": While a pigeon-shaped chest (pectus carinatum) can occur with CF due to chronic lung infections and hyperinflation, it is not the most immediate concern compared to respiratory therapy or infection control.
Correct Answer is C
Explanation
A. Lack of adequate ventricle strength to pump blood to the body: While right ventricular hypertrophy is part of Tetralogy of Fallot, the primary cause of fatigue is inadequate oxygenation, not muscle strength.
B. Restricted blood flow leaving the heart: This contributes to low oxygen levels but isn’t the direct reason for fatigue; the issue lies in oxygen availability for metabolism.
C. Inadequate oxygenation for supporting energy metabolism: The structural defects cause reduced oxygen delivery to tissues, leading to fatigue during activities like feeding.
D. Increased circulation pressure to the lungs: Pulmonary stenosis reduces blood flow to the lungs, but this doesn’t directly explain fatigue from eating.
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.