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 C
Explanation
A. Repeat the total bed bath and complete linen change: Repeating a full bed bath is not necessary unless the client is extensively soiled. It is more efficient and less disruptive to clean only the areas affected by incontinence while ensuring comfort and hygiene are maintained.
B. Place incontinent pads around the client's buttocks: While using incontinent pads helps manage future incontinence, it does not address the immediate need to clean the client and remove soiled linens, which is crucial to prevent skin breakdown and infection.
C. Cleanse any soiled skin and change the soiled linens: Cleaning the soiled skin and changing the linens is the best immediate response to maintain skin integrity, prevent infection, and promote client comfort. This targeted approach ensures the client remains clean without unnecessary interventions.
D. Spray a skin protectant around the perineal area: Applying a skin protectant is a helpful preventive measure after cleansing, but it should not be the first step. The priority is to remove feces and soiled linens before considering protective applications to the skin.
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"D"},"D":{"answers":"A"}}
Explanation
SBAR Format:
Situation:
I am holding the digoxin because the client's heart rate is too low.
Background:
The client is a 59-year-old male with hypertension and heart failure. He is currently taking furosemide and digoxin.
Assessment:
Heart rate is 48 beats/minute, blood pressure is 109/76 mm Hg.
Recommendation:
Do you want to recheck the digoxin level to see if there is toxicity? I will monitor the client's heart rate, blood pressure, and perfusion with a continuous monitor until his heart rate returns to normal.
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