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. "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.
Correct Answer is B
Explanation
A. Rectus abdominis: The rectus abdominis is a muscle in the abdomen, not the thigh. It is not used for intramuscular injections, as it does not provide the necessary mass or safe anatomical location for such injections.
B. Rectus femoris: The rectus femoris is located in the mid anterior thigh and is a common site for intramuscular injections, especially when other sites are not ideal. It provides easy access, sufficient muscle mass, and fewer major nerves or blood vessels.
C. Gluteus medius: The gluteus medius is located in the upper outer quadrant of the buttock, commonly used for dorsogluteal or ventrogluteal injections, not for injections into the anterior thigh.
D. Gluteus maximus: The gluteus maximus forms the bulk of the buttocks and is used for dorsogluteal injections. It is not located in the anterior thigh and is associated with greater risk of hitting major nerves like the sciatic nerve.
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