A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?

Recheck the client's SaO, level after having the client cough and clear their throat.

Review the client's most recent Sao, level in the medical record.

Notify the charge nurse of the client's condon.

Check the client's medical records to see which medications were recently administered.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Recheck the client's SaO2 level after having the client cough and clear their throat is correct. This action is crucial to ensure the accuracy of the SaO2 reading. Sometimes, minor obstructions or secretions in the airway can momentarily affect the oxygen saturation readings. Having the client cough and clear their throat may help improve the SaO2 readings by clearing any temporary blockages.

Choice B Reason:

Review the client's most recent SaO2 level in the medical record is incorrect. While reviewing the client's history is important, the immediate priority is to verify the current SaO2 level for accuracy before taking further action.

Choice C Reason:

Notify the charge nurse of the client's condition is incorrect. While it might eventually be necessary to inform other healthcare team members, the immediate action should focus on rechecking the SaO2 level to ensure the client's current oxygen saturation status.

Choice D Reason:

Check the client's medical records to see which medications were recently administered is incorrect. Knowing the client's recent medications is important for assessment, but it may not directly address the current situation of shortness of breath and low oxygen saturation. Rechecking the SaO2 level takes precedence in this acute situation.

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Correct Answer is ["A","C"]

Explanation

Explanation

Choice A Reason:

A client receives burns from a heating pad is correct. Any injury or harm caused to a client due to a medical device or equipment should be documented in an incident report for evaluation and review to prevent future incidents.

Choice B Reason:

A client's visitor becomes dizzy and faints in the client's room is incorrect. While this event might prompt the nurse to provide immediate assistance and seek medical attention for the visitor, it doesn't typically fall under the purview of an incident report unless it results from an issue within the healthcare facility.

Choice C Reason:

A client becomes disoriented and falls out of bed is correct. Falls resulting in injury or harm to the client, especially due to disorientation, should be documented to assess potential preventive measures and ensure appropriate care.

Choice D Reason:

A client reports being dissatisfied with the temperature of the meals provided is incorrect. Client dissatisfaction with meal temperature is an important concern, but it's generally addressed through communication and service improvement rather than being documented in an incident report unless it poses a risk to the client's health (e.g., if the food was excessively hot, causing harm).

A. "I'll use focused breathing to control my pain." B. "I'll learn to notice the sensation of muscle tension." C. "I'll think about my grandfather's farm to reduce pain." D. "I'll listen to my favorite music to take my mind off the pain."

Correct Answer is C

Explanation

Choice A Reason:

"I'll use focused breathing to control my pain." Is incorrect. Focused breathing is a relaxation technique that can complement guided imagery, but it's not specifically imagery-based. It's more aligned with techniques like mindfulness or deep breathing exercises.

Choice B Reason:

"I'll learn to notice the sensation of muscle tension." Is incorrect. Noticing muscle tension is a part of progressive muscle relaxation, a different technique aimed at reducing physical tension, which is different from guided imagery.

Choice C Reason:

"I'll think about my grandfather's farm to reduce pain." Is correct. Guided imagery involves focusing on specific mental images or scenarios to promote relaxation, reduce stress, and manage pain. Imagining a peaceful or pleasant place, like the client's grandfather's farm, can serve as a distraction and help reduce pain perception.

Choice D Reason:

"I'll listen to my favorite music to take my mind off the pain." Is incorrect. Listening to music can be a distraction technique, but it's not specifically guided imagery. While it might help in managing pain by diverting attention, it's not rooted in imagery-focused mental visualization.

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A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?

Nursing Test Bank

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Correct Answer is ["A","C"]

Explanation

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Correct Answer is C

Explanation

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