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 E,C,B,D,A

Explanation

E. Disconnect the tube from the suction device:

Before starting the removal process, it's essential to disconnect the tube from any suction to prevent discomfort or injury to the client during removal.

C. Instill 50 mL of air into the tube:

Instilling air into the tube helps clear any residual contents and lubricates the tube, making it easier and more comfortable to remove.

B. Ask the client to take a deep breath:

Instructing the client to take a deep breath helps relax the throat and upper esophageal muscles, making the removal process smoother and potentially less uncomfortable.

D. Pinch and withdraw the tube:

Withdrawing the tube while the client holds their breath aids in a controlled removal, minimizing discomfort or risk of aspiration.

A. Apply clean gloves:

Lastly, applying clean gloves ensures infection control and maintains cleanliness during the removal process, preventing any potential contamination.

A. Remove 45 mL of urine from the catheter with a syringe. B. Clamp the catheter tubing for 60 min. C. Clamp the catheter tubing below the needleless port D. Place the specimen in a clean specimen cup.

Correct Answer is A

Explanation

Choice A Reason:

Removing 45 mL of urine from the catheter with a syringe is correct. To obtain a sterile urine specimen from an indwelling urinary catheter, the nurse should use a sterile syringe to aspirate a specific volume of urine from the catheter tubing. This method ensures minimal contamination and an accurate representation of the urine in the bladder at that moment.

Choice B Reason:

Clamping the catheter tubing for 60 min is incorrect.

Clamping the catheter tubing can lead to potential complications such as urinary retention, backflow of urine, or discomfort for the client. It's not a standard practice and could compromise the client's care.

Choice C Reason:

Clamping the catheter tubing below the needleless port is incorrect.

Clamping the catheter tubing can disrupt the urinary drainage and potentially cause issues like urinary stasis or increase the risk of infection. It's not an appropriate method for collecting a sterile urine specimen.

Choice D Reason:

Place the specimen in a clean specimen cup is incorrect. While placing the specimen in a clean cup is necessary, the method of collecting a urine sample from an indwelling catheter involves using a sterile syringe to aspirate a specific volume of urine directly from the catheter tubing, rather than pouring it into a cup from the collection bag.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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