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 ["B","F","G","H"]

Explanation

Vital signs are to be taken every 4 hours, as per the physician's orders. The correct times based on the 4-hour interval are:

H. 0800 (Initial time)

B. 1200 (4 hours after 0800)

F. 1600 (4 hours after 1200)

G. 2000 (4 hours after 1600)

A. Show acceptance of the client's current feelings. B. Share a similar personal experience. C. Document the behavior in the client's record. D. Ask the palliative care nurse to see the client. E. Allow the client a time to continue crying.

Correct Answer is ["A","C","D","E"]

Explanation

A. Show acceptance of the client's current feelings: Accepting the client’s emotional response without judgment builds trust and provides emotional support, which is critical when coping with a new diagnosis of advanced cancer.
B. Share a similar personal experience: Sharing personal experiences shifts the focus away from the client’s feelings and can be perceived as minimizing their unique emotional response. It is more therapeutic to focus entirely on the client’s experience.
C. Document the behavior in the client's record: Accurate documentation of the client's emotional state ensures continuity of care and alerts other healthcare providers to the client's need for emotional support and potential interventions.
D. Ask the palliative care nurse to see the client: Involving a palliative care specialist provides expert emotional, spiritual, and symptom management support, which is appropriate for a client newly diagnosed with stage IV cancer.
E. Allow the client a time to continue crying: Allowing the client to cry acknowledges their need to express grief and emotion. It helps the client begin processing the overwhelming news and supports healthy emotional expression.

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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

Exhibits Review H and P, nurse's notes, flow sheet, laboratory values, prescriptions, and imaging studies. Highlight the times that the practical nurse (PN) should measure vital signs. A. 1000 B. 1200 C. 1500 D. 1400 E. 1800 F. 1600 G. 2000 H. 0800

Correct Answer is ["B","F","G","H"]

Explanation

A client who is recently diagnosed with stage IV ovarian cancer tells the practical nurse (PN) that the staff on the unit are insensitive and begins to cry. Which intervention(s) should the PN implement? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

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While applying sterile gloves (open method), which action should the practical nurse (PN) take to ensure that surgical asepsis is maintained?

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