A nurse is obtaining vital signs on a client in a clinic. The client's oxygen saturation (SpO2) is 93% on room air while the client is talking during the assessment. Which action should the nurse take next?

Apply supplemental oxygen via nasal cannula

Document the finding as an abnormal assessment result

Notify the healthcare provider of the low oxygen level

Ask the client to stop talking and recheck the oxygen saturation

Answer and Explanation

The Correct Answer is D

Choice A reason: Applying supplemental oxygen is an intervention that requires a definitive assessment of hypoxia. In a clinic setting, an SpO2 of 93% while talking may be a transient reading caused by physical activity or motion artifact. The nurse must first ensure the accuracy of the data before initiating medical therapy.

Choice B reason: Documenting a result as abnormal without first verifying its accuracy is premature. Pulse oximetry is highly sensitive to movement and speech, which can interfere with the sensor's ability to maintain a consistent plethysmographic waveform. Verification is a required step in the nursing process before final documentation.

Choice C reason: Notifying the healthcare provider is indicated only after a persistent and accurate low oxygen level is confirmed. Jumping to notification before re-evaluating the client under stable conditions—such as while resting and quiet—may lead to unnecessary clinical alarms and potentially incorrect medical interventions based on flawed data.

Choice D reason: Talking can cause fluctuations in respiratory depth and motion at the sensor site, leading to an artificially low or inconsistent SpO2 reading. Asking the client to remain still and quiet for a full minute allows the oximeter to stabilize and provide a more accurate reflection of the true arterial oxygen saturation.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Palpation for lower extremity edema is a specialized physical examination technique used to assess fluid volume status. It is not considered part of the initial general inspection or survey, which focuses on global observations that can be made without physically manipulating or touching the patient's limbs.

Choice B reason: Inquiring about nutritional intake is a component of the health history or subjective data collection. While important for clinical context, it is an interview technique rather than a visual inspection. General inspection relies on the nurse’s objective observations of the patient's physical state upon first encounter.

Choice C reason: General inspection begins the moment the nurse encounters the patient. Observing skin color and level of consciousness provides immediate data regarding the patient's physiological and neurological stability. This visual survey ensures the patient is safe and coherent before proceeding with more invasive or time-consuming physical measurements.

Choice D reason: Lung auscultation is a specific assessment technique following inspection and palpation in the sequence of a respiratory exam. It requires the use of a stethoscope and physical contact. General inspection must precede auscultation to identify any obvious signs of respiratory distress that might require immediate intervention.

A. Measure blood pressure while client is lying, sitting, and standing B. Record any drop in systolic BP of 20 mmHg or more C. Provide water before the test D. Ask the client to walk during the test E. Wait 1-2 minutes between each position change

Correct Answer is ["A","B","E"]

Explanation

Choice A reason: The procedure for detecting orthostatic (postural) hypotension requires sequential blood pressure and pulse measurements in three distinct positions: supine, sitting, and standing. This allow the nurse to observe how the cardiovascular system compensates for the gravitational shifts in blood volume during position changes.

Choice B reason: Orthostatic hypotension is clinically defined as a decrease in systolic blood pressure of at least 20 mmHg or a decrease in diastolic blood pressure of at least 10 mmHg within three minutes of standing. Recording these specific drops is essential for a definitive diagnosis of the condition.

Choice C reason: Providing water before the test could artificially inflate the blood volume and mask orthostatic hypotension. The goal of the test is to evaluate the body's baseline compensatory mechanisms. Adding fluids would interfere with the accuracy of the assessment by temporarily correcting potential dehydration-induced hypotension.

Choice D reason: The client must remain still during each measurement to ensure an accurate blood pressure reading. Walking or physical activity during the test would stimulate the sympathetic nervous system and muscular pump, which could falsely elevate the blood pressure and invalidate the results of the orthostatic assessment.

Choice E reason: A brief rest period of 1 to 2 minutes (sometimes up to 3 minutes) between each position change is necessary to allow the blood to redistribute and the baroreceptor reflex to respond. Taking the measurement too quickly would not give the body enough time to show a true postural reaction.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is obtaining vital signs on a client in a clinic. The client's oxygen saturation (SpO2) is 93% on room air while the client is talking during the assessment. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing student is obtaining vital signs, which action correctly of general inspection should be performed before assessment measurements?

Correct Answer is C

Explanation

A nurse is assessing a client for orthostatic hypotension. Which actions should the nurse take during the assessment? (Select all that apply)

Correct Answer is ["A","B","E"]

Explanation

A nurse is preparing to interview a client to obtain a health history. Which actions should the nurse take to promote effective communication and accurate data collection? (Select all that apply)

A nurse is caring for a client whose cultural beliefs prohibit certain foods. The client is on a hospital diet. What should the nurse do first?

A nurse is providing teaching on health promotion strategies to a group of college students. Which of the following is an example of primary prevention?

Which of the following is an example of objective data?

A nurse is preparing to examine a client's tympanic membrane. Which instrument should the nurse use to perform this assessment?

During a physical assessment the nurse observes that the client's skin is warm, dry, and slightly flushed. This type of information is considered

A nurse is assessing a patient who reports abdominal pain, which question best addresses the R (Radiation) component of the OLD CARTS pain assessment?

During a physical assessment which question best evaluates a client's self-care abilities?