Name: Betty Jo Farlow
Provider. R. Schulze,
MD Code Status:
Full Code Allergies: NKA
Age: 41 years
Weight: 66.36 kg
Review the electronic health record. The nurse is working with an unlicensed assistive personnel (UAP). The UAP reports the client's vital signs as charted in the electronic health record. Which action should the nurse take?
The nurse should report the UAP's behavior to the manager.
The nurse should ask the UAP to retake the client's vital signs.
The nurse should prepare to administer oxygen therapy.
The nurse should reassess the client's pulse oximetry.
The Correct Answer is D
A. There is no evidence of inappropriate behavior by the UAP. The UAP accurately reported the vital signs. There is no indication of misconduct or negligence that would require reporting to a manager.
B. Although one value is abnormal, the nurse should not delegate reassessment of an abnormal finding back to the UAP. When abnormal data are reported, the registered nurse is responsible for validating and further assessing the finding personally. Re-delegating does not meet the RN’s accountability for clinical judgment.
C. A pulse oximetry reading of 91% on room air is below normal (normal is 95–100%), indicating mild hypoxemia. However, before initiating an intervention such as oxygen therapy, the nurse must first validate the abnormal finding. Pulse oximetry readings can be affected by poor probe placement, cold extremities, nail polish, motion, or equipment error. Immediate oxygen administration without reassessment is premature.
D. A pulse oximetry of 91% is abnormal and requires follow-up. The nurse’s first action should be to personally reassess the oxygen saturation to validate the accuracy of the reading. This includes checking probe placement, ensuring proper perfusion, and assessing the client’s respiratory status. Once validated, appropriate interventions such as oxygen therapy can be initiated if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Reports of mucus buildup are subjective because they rely on the client’s personal perception and self-report. Subjective data are symptoms, not directly measurable by the nurse.
B. Tympanic membrane translucent is an objective finding because it can be observed and measured during otoscopic examination. Objective data are measurable or visible signs that the nurse can directly assess. The translucency of the tympanic membrane indicates a healthy ear without infection or fluid buildup.
C. Pain and tenderness behind the ear are primarily subjective, as pain is reported by the client. While tenderness can be assessed by palpation, the pain component is still experienced by the client, making it partially subjective.
D. Coughing and sneezing may be observable, but they are not specific to the ear and are typically considered related to upper respiratory symptoms, not direct objective data from an ear assessment.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
- “Are you taking any medications that would cause xerostomia?” – Mouth
Xerostomia, or dry mouth, is a condition that affects the oral cavity. Certain medications, such as antihypertensives, antihistamines, and antidepressants, reduce salivary production. Asking this question helps identify potential oral complications like increased risk for dental caries, gum disease, and difficulties with swallowing, which are all directly related to mouth health rather than head or neck structures. - “How often do you go to the dentist?” – Mouth
Regular dental visits are a direct indicator of oral health maintenance. This question assesses preventive oral care, including evaluation of teeth, gums, and overall mouth hygiene. It does not pertain to the structural or functional assessment of the head or neck. - “Do you have difficulty chewing or swallowing food?” – Mouth
Difficulty with chewing (mastication) or swallowing (dysphagia) involves the teeth, tongue, oral cavity muscles, and pharynx. These functions are part of the mouth and upper digestive tract. Identifying these issues can help detect oral or neurologic problems that specifically affect feeding and nutrition. - “Have you had any unusual or frequent headaches?” – Head and Neck
Headaches are neurologic symptoms originating in the brain or cranial structures and may be associated with vascular, muscular, or intracranial causes. This assessment helps evaluate the head region for conditions like migraines, tension headaches, or other neurologic disorders, which are unrelated to the oral cavity. - “Do you have a history of traumatic brain injury?” – Head and Neck
Traumatic brain injury (TBI) involves structural or functional damage to the brain and possibly the cranial nerves. Assessing history of TBI is essential for evaluating cognitive, sensory, and motor functions of the head and neck, including vision, hearing, balance, and neck mobility. This is unrelated to oral health.
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