During assessment of a client on the respiratory unit, the pulse oximetry monitor indicates a drop of SpO2 from 98% to 87% over four hours in a client who previously had normal range oxygen saturation level. Which of the following actions should the nurse perform first?

Administer supplemental oxygen to the client.

Check the position of the pulse oximeter probe and ensure it is properly attached.

Assess the client's airway for obstruction.

Notify the healthcare provider immediately.

Answer and Explanation

The Correct Answer is B

A. Administering supplemental oxygen is appropriate if the low oxygen saturation is confirmed, but the nurse should first verify the accuracy of the reading to avoid unnecessary interventions.

B. Checking the position of the pulse oximeter probe and ensuring it is properly attached is the first step. Faulty probe placement or technical issues can cause inaccurate readings, so confirming the validity of the drop in SpO2 is essential before taking further action.

C. Assessing the client's airway for obstruction is critical if the low SpO2 is verified and no technical issues are found. However, this step follows confirming the accuracy of the pulse oximetry reading.

D. Notifying the healthcare provider is necessary if the drop in SpO2 is confirmed and persists despite initial nursing interventions, but it is not the first action.

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Correct Answer is D

Explanation

A. Oral hydration is important for overall health and to thin secretions, but it is not the immediate intervention to address dyspnea and wheezing in COPD.

B. Pursed-lip breathing is a helpful technique for managing chronic symptoms of COPD and improving airflow, but it is not the first step in managing acute symptoms like dyspnea and wheezing.

C. Corticosteroid therapy may be part of the treatment for COPD exacerbations, but it is not the initial intervention for acute symptoms. It is typically used after bronchodilators like SABA have been administered.

D. A short-acting beta-agonist (SABA), such as albuterol, is the first-line treatment for acute dyspnea and wheezing in COPD. It works by relaxing the bronchial muscles, opening the airways, and improving airflow.

A. A musty odor is normal as the cast ages. B. Apply ice to your foot after walking. C. There is no need to cover the cast when showering. D. Report any numbness or pain in your toes.

Correct Answer is D

Explanation

A. A musty odor is not normal and may indicate the presence of infection or moisture inside the cast. The client should report any unusual odors to the healthcare provider.

B. Applying ice to the foot after walking is not typically recommended for a Plaster of Paris cast. The client should focus on elevating the leg to reduce swelling and avoid getting the cast wet.

C. The cast must be kept dry to maintain its integrity. The client should cover the cast with a waterproof covering when showering to prevent damage or weakening of the plaster.

D. Numbness or pain in the toes may indicate impaired circulation or nerve compression, which are serious complications that require immediate medical attention. The client should be instructed to report these symptoms promptly.

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During assessment of a client on the respiratory unit, the pulse oximetry monitor indicates a drop of SpO2 from 98% to 87% over four hours in a client who previously had normal range oxygen saturation level. Which of the following actions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with chronic obstructive pulmonary disease (COPD) presents with dyspnea and wheezing. What is the most appropriate initial nursing intervention to manage these symptoms?

Correct Answer is D

Explanation

A nurse is providing discharge teaching to a client who has a Plaster of Paris walking cast on his left lower leg. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

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