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. Provide a PRN hypnotic medication: Administering a hypnotic should not be the first response without first assessing the underlying cause of the sleep difficulty. Non-pharmacological approaches are safer, especially for older adults who are more sensitive to sedative side effects.
B. Reassure the client that it is still early: Simply reassuring the client does not address the immediate concern of why the client cannot sleep. Dismissing the complaint without assessment may lead to prolonged distress and unresolved sleep disturbances.
C. Evaluate the room environment: Assessing the room for factors like noise, lighting, temperature, and comfort is a priority because environmental factors often contribute significantly to insomnia. Addressing modifiable conditions can promote natural sleep without immediately resorting to medications.
D. Close the door to the client's room: While closing the door might reduce noise, it is a single action that may not fully address all potential environmental issues affecting sleep. A complete evaluation of the environment is necessary first to identify and correct all possible disruptions.

A. Provide a Yankauer tip for oral suction. B. Swab the oral cavity with a washcloth. C. Support the head with a small pillow. D. Use oral swabs with normal saline.

Correct Answer is D

Explanation

A. Provide a Yankauer tip for oral suction: A Yankauer suction device is useful for clearing large amounts of oral secretions but is typically used when secretions are too excessive to manage with swabbing alone. In routine oral care for an unconscious client, gentle cleaning with swabs is safer and minimizes mucosal trauma.
B. Swab the oral cavity with a washcloth: Using a washcloth in an unconscious client's mouth can be unsafe because it is bulky, can cause trauma to delicate tissues, and increases the risk of aspiration if too much fluid or debris is present. Oral swabs are designed to be safer and more appropriate for this purpose.
C. Support the head with a small pillow: While supporting the head ensures comfort, it does not directly address the priority need of safely and thoroughly cleaning the oral cavity to maintain hygiene and prevent infection. Airway protection and thorough cleaning are the primary concerns during oral care.
D. Use oral swabs with normal saline: Using oral swabs moistened with normal saline is the best intervention because it gently cleanses the mucous membranes, maintains moisture, and reduces the risk of mucosal injury. Normal saline is safe and non-irritating, which is critical for unconscious clients at risk for aspiration and mucosal breakdown.

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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

At 2100, an older adult client turns on the call light and reports to the practical nurse (PN) the inability to fall asleep. Which is the priority nursing action?

Correct Answer is C

Explanation

While providing oral care for a client who is unconscious, the practical nurse (PN) positions the client laterally and uses a basin to collect secretions. Which intervention is best for the PN to implement?

Correct Answer is D

Explanation

While performing a physical assessment on a client with chronic obstructive pulmonary disease (COPD), the practical nurse (PN) determines that the client's respiratory rate is 30 breaths/minute. When the PN begins to assess the client's range of motion (ROM), which is the best plan to implement?

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In assisting a dyspneic client with morning care, which action by the practical nurse (PN) is most important?

The practical nurse (PN) is preparing to provide a change of shift report when an oncoming nurse arrives, appearing intoxicated, and who describes to another colleague about drinking all afternoon and almost forgetting to come to work. Which action should the PN take first?