A nurse is monitoring a client’s oxygen saturation using a pulse oximeter. The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula.
Which of the following actions should the nurse take?

Reposition the sensor probe.

Apply a cooling blanket to the client.

Place the client in a side-lying position.

Ambulate the client.

Answer and Explanation

The Correct Answer is A

The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula, which is below the normal range of 95% to 100%.

This could indicate that the client is not receiving enough oxygen or that the pulse oximeter is not working properly.

The nurse should first check the sensor probe for any problems, such as poor attachment, nail polish, cold extremities, or motion artifact.

Repositioning the sensor probe may improve the accuracy of the reading and help the nurse determine the next course of action.

Choice B. Apply a cooling blanket to the client is wrong because a cooling blanket is used to lower the body temperature of a client with fever or hyperthermia.

It has no effect on the oxygen saturation level.

Choice C. Place the client in a side-lying position is wrong because a side-lying position may not improve the oxygenation of the client.

A more appropriate position would be a high Fowler’s position, which allows for maximum lung expansion and gas exchange.

Choice D. Ambulate the client is wrong because ambulating the client may worsen the oxygen saturation level if the client has a respiratory condition that causes hypoxemia.

The nurse should assess the client’s respiratory status and oxygen therapy before ambulating the client.

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Correct Answer is D

Explanation

The nurse should remove the gloves first because they are the most contaminated piece of personal protective equipment (PPE) and should be discarded as soon as possible.

The nurse should then remove the gown, which may also be soiled with blood or body fluids, by grasping it at the neck and peeling it off inside out.

The mask and goggles should be removed last, by touching only the straps or earpieces, and avoiding touching the front of the mask or the lenses of the goggles.

Choice A is wrong because goggles are not the most contaminated piece of PPE and should be removed after the gown.

Choice B is wrong because gown is not the most contaminated piece of PPE and should be removed after the gloves.

Choice C is wrong because mask is not the most contaminated piece of PPE and should be removed after the gown and goggles.

Normal ranges for wound irrigation pressure are between 4 and 15 psi (pounds per square inch).

Higher pressures may damage the wound tissue and increase the risk of infection.

Lower pressures may not be effective in removing debris and bacteria from the wound.

A. Remove the device from the room. B. Access the facility’s maintenance protocol. C. Report defective equipment. D. Request a replacement device.

Correct Answer is A

Explanation

This is because a frayed electrical cord can pose a serious risk of electric shock or fire to the client and the nurse.

The nurse should act quickly to eliminate the hazard and ensure the safety of the client and others.

Choice B is wrong because accessing the facility’s maintenance protocol is not the first action the nurse should take.

The nurse should prioritize removing the device from the room before following any protocol.

Choice C is wrong because reporting defective equipment is not the first action the nurse should take.

The nurse should prioritize removing the device from the room before reporting it to the appropriate authority.

Choice D is wrong because requesting a replacement device is not the first action the nurse should take.

The nurse should prioritize removing the device from the room before requesting a new one.

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A nurse is monitoring a client’s oxygen saturation using a pulse oximeter. The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take?

Nursing Test Bank

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A nurse is monitoring a client’s oxygen saturation using a pulse oximeter. The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula.
Which of the following actions should the nurse take?