During vital sign assessment of a client, the practical nurse (PN) counts the left radial pulse at 88 beats/minute, and the pulse oximeter clipped to a finger on the left hand records a pulse rate of 68 beats/minute with an oxygen saturation of 95%. Which of the following should the PN do first?
Notify the charge nurse.
Reposition the oximeter clip.
Document the conflicting data.
Measure the blood pressure.
The Correct Answer is B
A. Notify the charge nurse: Notifying the charge nurse would be appropriate if the discrepancy persists after troubleshooting. However, first steps should involve checking the equipment to rule out technical errors before escalating the concern.
B. Reposition the oximeter clip: A discrepancy between the manual pulse and the pulse oximeter reading often indicates a technical issue, such as poor sensor placement or poor perfusion. Repositioning the oximeter clip ensures accurate data collection before proceeding with further interventions.
C. Document the conflicting data: Documentation is important, but before recording inconsistent or potentially inaccurate findings, the nurse should first validate the data by ensuring correct technique and equipment function.
D. Measure the blood pressure: Measuring blood pressure is part of a full vital signs assessment but does not address the immediate concern of conflicting pulse readings. Equipment issues must be corrected first to ensure all vital signs are accurate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Check the medical record to verify the medication's name and strength: The first action is to verify the medication against the medical record to ensure it is the correct drug, dose, and formulation. This prioritizes patient safety by confirming accuracy before administration, preventing possible medication errors.
B. Reassure the client that the blue tablet is the correct medication: Reassuring the client without verifying the medication could risk administering the wrong drug. Even if the nurse believes the medication is correct, professional standards require verification when a discrepancy is noted by the patient.
C. Explain that the tablets are from different manufacturers: Differences in tablet appearance between manufacturers are common, but assuming this without verifying could result in a serious medication error. Visual differences should always be validated against the order and pharmacy records first.
D. Withhold the medication and notify the healthcare provider: Withholding the medication and notifying the healthcare provider may be appropriate if verification reveals a problem. However, the first step is to check the medical record to determine if the medication given matches the prescribed drug and dose.
Correct Answer is B
Explanation
A. Extend thumb at a right angle during gloving: Positioning the thumb may help with glove placement but does not directly maintain surgical asepsis. The focus of aseptic technique is keeping gloves sterile, not thumb positioning during the process.
B. Keep gloved hands in sight above waist level: Keeping hands in sight and above waist level is essential for maintaining surgical asepsis. Anything below waist level is considered contaminated, and visibility ensures that sterility is not compromised during procedures.
C. Touch cuff fold only while applying second glove: Touching the cuff is appropriate when donning the second glove, but maintaining hand position above waist level is a broader and ongoing requirement to uphold sterile technique throughout the procedure.
D. Apply a mask once both hands are gloved: Masks should already be in place before starting the sterile gloving procedure. Waiting to apply a mask after donning sterile gloves risks contaminating the gloves and breaking sterile technique.
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