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 C

Explanation

A. Buck's extension traction is not used to reduce fractures but to provide comfort, maintain alignment, and reduce muscle spasms in the affected area. Reduction of the fracture typically occurs through surgical intervention.

B. Buck's extension traction is not used to maintain the alignment of pins, as there are no pins involved in this type of traction. It is designed to relieve muscle spasms and provide comfort to the affected limb.

C. Buck's extension traction is primarily used to relieve muscle spasms and provide a steady pull on the affected limb to maintain alignment and reduce pain. This is particularly important in hip fractures to prevent further injury and discomfort.

D. Buck's extension traction does not allow for supported movement of the extremity; instead, it helps to immobilize the limb and reduce muscle spasms.

A. Obtain intravenous access. B. Computed tomography (CT) of the chest C. Thoracentesis D. Obtain ABGS. E. Pulmonary Function Tests (PFTS) F. Prepare for insertion of a chest tube

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

Potential Prescription	Anticipated	Non- essential	Contraindicated
Obtain intravenous access.	✓
Computed tomography (CT) of the chest	✓
Thoracentesis		✓
Obtain ABGS.	✓
Pulmonary Function Tests (PFTS)			✓
Prepare for insertion of a chest tube	✓

Rationale

Obtain intravenous access: Anticipated. IV access is crucial for administering fluids, medications (like pain management), and potentially blood products if needed.
Computed tomography (CT) of the chest: Anticipated. A CT scan provides a detailed image of the chest cavity and can confirm the diagnosis of pneumothorax, as well as identify the size and location of the air accumulation.
Thoracentesis: Non-essential. A thoracentesis is a procedure to remove fluid from the pleural space. In a pneumothorax, the issue is air accumulation, not fluid. While a hemothorax (blood in the pleural space) can sometimes accompany a pneumothorax, the provided information does not indicate this. A chest tube is the appropriate intervention for air.
Obtain ABGs (Arterial Blood Gases): Anticipated. ABGs provide essential information about the client's oxygenation, ventilation, and acid-base balance. Given the client's low O2 saturation and respiratory distress, ABGs are necessary to assess the severity of respiratory compromise.
Pulmonary Function Tests (PFTs): Contraindicated. Pulmonary function tests are not appropriate in the acute setting of a pneumothorax as they can exacerbate the condition and are not useful for immediate management.
Prepare for insertion of a chest tube: Anticipated. A chest tube is the definitive treatment for a pneumothorax. It allows for the evacuation of air from the pleural space and re-expansion of the lung. Given the client's symptoms (dyspnea, low O2 saturation, absent lung sounds), a chest tube is highly likely to be required

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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 nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching?

Correct Answer is C

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

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