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 B

Explanation

A. Rhonchi are low-pitched, coarse sounds heard during both inspiration and expiration. They are typically associated with mucus or secretions in the larger airways and do not match the description of high-pitched squeaking sounds.

B. Wheezes are high-pitched, continuous sounds heard primarily during expiration. They result from narrowed airways, which are characteristic of asthma. The description provided matches wheezes, making this the correct documentation.

C. Stridor is a high-pitched sound heard predominantly during inspiration and is associated with upper airway obstruction. It does not match the description of sounds heard during exhalation.

D. Crackles are discontinuous, popping sounds heard during inspiration and are associated with fluid in the alveoli or smaller airways. They do not match the high-pitched squeaking sounds described.

A. Hypertension B. Hypoglycemia C. Polyuria D. Oral candidiasis

Correct Answer is D

Explanation

A. Hypertension is not a common adverse effect of Beclomethasone, an inhaled corticosteroid. Systemic effects like hypertension are rare with inhaled forms due to minimal systemic absorption.

B. Hypoglycemia is not associated with Beclomethasone use. Corticosteroids are more likely to cause hyperglycemia, but this is uncommon with inhaled formulations.

C. Polyuria is not an expected side effect of Beclomethasone. It is more commonly associated with conditions like diabetes or diuretics.

D. Oral candidiasis (thrush) is a common adverse effect of inhaled corticosteroids like Beclomethasone. The medication can suppress local immunity in the oral mucosa, leading to fungal overgrowth. Clients should be advised to rinse their mouth after each use to reduce this risk.

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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

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