A nurse is evaluating a client's oxygen saturation reading of 97% on room air. How would the nurse interpret this result? Select all that apply
The client does not need further intervention.
The client has an abnormal oxygen saturation.
The client has a normal oxygen saturation.
The client may have an inaccurate reading.
The client may have chronic lung conditions.
Correct Answer : A,C
A. Since the reading is within the normal range, the client does not require immediate interventions such as supplemental oxygen or advanced respiratory support. Routine monitoring and continued assessment are sufficient unless there are other clinical signs of respiratory compromise, such as increased work of breathing, cyanosis, or altered mental status.
B. An oxygen saturation below 95% is generally considered abnormal in most healthy adults, as it may indicate hypoxemia or impaired gas exchange. A reading of 97% is normal and does not indicate the presence of hypoxia or inadequate oxygen delivery.
C. A SpO₂ of 97% confirms that hemoglobin in the client’s blood is adequately carrying oxygen. This is reassuring and suggests that the client’s respiratory and circulatory systems are functioning appropriately at the time of assessment.
D. Pulse oximetry readings can sometimes be affected by factors such as nail polish, poor perfusion, movement, or cold extremities. While these factors can cause inaccurate readings, the scenario does not provide any evidence suggesting inaccuracy. Therefore, it is reasonable to interpret this reading as accurate unless there are other signs or symptoms that would prompt verification.
E. Clients with chronic lung diseases such as chronic obstructive pulmonary disease (COPD) may have baseline oxygen saturations lower than 95%. However, a reading of 97% does not indicate the presence or absence of chronic lung disease. Without additional history or clinical findings, it is not possible to infer chronic lung conditions from a single normal reading.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This is an intervention, not a goal. Applying barrier cream is a specific nursing action used to prevent skin breakdown, but goals should focus on desired client outcomes rather than tasks performed by the nurse.
B. Assessing the skin is an important part of care and a nursing intervention, but it does not describe the expected end result or outcome for the client. Goals should reflect what the client is expected to achieve or maintain.
C. This is the most appropriate goal for a client at risk for skin breakdown. It is client-centered, measurable, and outcome-oriented, indicating the desired result of nursing interventions. Maintaining intact skin directly reflects prevention of pressure injuries, abrasions, or other skin compromise.
D. While minimizing pain is important, it is not the primary goal related to the risk of skin breakdown unless the client is already experiencing painful lesions. The priority for a client at risk is preventing skin compromise.
Correct Answer is D
Explanation
A. Acne develops primarily due to overactive sebaceous glands, hormonal fluctuations, and bacterial colonization of the skin, particularly Propionibacterium acnes. While acne may occur in people of all skin types, genetically high melanin density does not predispose an individual to developing acne. Therefore, it is not a complication specifically associated with increased melanin levels.
B. Contact dermatitis is an inflammatory reaction caused by exposure to irritants or allergens. It is not directly related to melanin density. People with high melanin may experience contact dermatitis similarly to others, but having more melanin does not inherently increase the risk of developing this condition.
C. Darker skin contains higher levels of melanin, which reduces the skin’s ability to synthesize vitamin D from sunlight. While this is a known risk factor for vitamin D deficiency, the question asks specifically about a skin-related complication, not a nutritional or systemic condition. Therefore, vitamin D deficiency is not the most appropriate answer here.
D. Keloids are excessive overgrowths of scar tissue that develop at the site of skin injury, often extending beyond the original wound margins. People with genetically higher melanin density, particularly individuals of African, Hispanic, or Asian descent, have a higher predisposition to keloid formation. The increased melanin is associated with more active fibroblast proliferation and excessive collagen deposition, which contributes to abnormal scarring. Keloids can result from minor skin injuries, surgical incisions, piercings, or even acne lesions.
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