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.
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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Related Questions
Correct Answer is D
Explanation
This food has the highest vitamin C content among the four options, with about 80 to 100 mg of vitamin C per fruit.
Vitamin C is a water-soluble vitamin that acts as an antioxidant and helps with wound healing, immune function, collagen synthesis, and iron absorption.
Choice A is wrong because 1 medium fresh green pear has only about 4 to 5 mg of vitamin C per fruit.
Pears are a good source of fiber and potassium, but not vitamin
C. Choice B is wrong because 1 small apple with the skin has only about 8 to 9 mg of vitamin C per fruit.
Apples are a good source of fiber and flavonoids, but not vitamin
C. Choice C is wrong because 1 small banana has only about 10 to 11 mg of vitamin C per fruit.
Bananas are a good source of potassium, magnesium, and vitamin B6, but not vitamin
Correct Answer is D
Explanation
The correct answer is choice D. This type of device is useful for a client who cannot assist.
A mechanical lift is used to transfer residents who cannot support their own weight.
It does not require the client to use upper body strength, as choice A suggests.
The lower end of the sling should go under the client’s thighs, not below the calves, as choice B states.
The sides of the sling are not for the client to hold on to, but for the caregiver to attach to the hooks on the lift, as choice C implies.
Therefore, choices A, B and C are wrong because they do not reflect the proper use of a mechanical lift.
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