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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. "With whom have you shared your feelings?": While this question encourages emotional expression, it is more appropriate once the client is calm and ready to discuss coping strategies. Immediate emotional support is needed first.
B. "Are you having any difficulty focusing at work?": Asking about work performance is not the priority when the client is currently overwhelmed by anxiety and struggling with basic self-care. Stabilizing the client emotionally is more urgent.
C. "Would you like me to sit with you for a while?": Offering presence and emotional support helps the client feel safe and less isolated during intense anxiety. This immediate action builds trust, reduces anxiety, and prepares the client for further assessment later.
D. "Have you experienced changes in your life recently?": Life changes are important to explore, but first the client needs reassurance and stabilization. Once the client is calmer, deeper assessment about life stressors can be conducted more effectively.

A. "Have you experienced anxiety or anger?" B. "Have you been able perform daily activities?" C. "Have you had suicidal thoughts?" D. "Have you joined any support groups?"

Correct Answer is C

Explanation

A. "Have you experienced anxiety or anger?": Feelings of anxiety and anger are common in anticipatory grief, but while important, they do not represent the most urgent safety concern compared to assessing for suicidal ideation.
B. "Have you been able to perform daily activities?": Evaluating functional status is important but is not the highest priority when first assessing a client’s emotional and psychological response to a terminal diagnosis.
C. "Have you had suicidal thoughts?": Assessing for suicidal ideation is the highest priority because clients facing a terminal illness may experience overwhelming despair. Ensuring the client’s immediate safety must come before addressing emotional support or coping mechanisms.
D. "Have you joined any support groups?": Participation in support groups is helpful for emotional healing, but determining the client's current mental health status and safety must be addressed before exploring support resources.

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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?

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is caring for a client who is experiencing overwhelming anxiety and difficulty performing self care. Which question should the PN ask first?

Correct Answer is C

Explanation

A practical nurse (PN) is providing care to a client who recently received a terminal illness diagnosis. Which question by the PN is the highest priority when assessing anticipatory grief?

Correct Answer is C

Explanation

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