The nurse cares for a client with a heart rate of 52 beats per minute. How should the nurse interpret this finding?

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.

• Squinting during the visual acuity exam – Abnormal
  Squinting may indicate visual impairment such as refractive errors (myopia, hyperopia, or astigmatism) or difficulty focusing. A normal response is being able to read the chart without compensatory behaviors.
• Yellowing of the sclera – Abnormal
  Yellow sclera indicates jaundice, which can result from liver dysfunction, hemolysis, or bile duct obstruction. Sclera should normally be white.
• Reflection of light in the same spot on each eye – Normal
  This demonstrates proper alignment of the eyes and normal corneal light reflex, indicating no strabismus or ocular misalignment.
• Gaze fixed and steady – Normal
  A fixed and steady gaze shows normal extraocular muscle function and cranial nerve integrity. Abnormal findings would include nystagmus or uncontrolled eye movements.
• Clear conjunctiva – Normal
  Normal conjunctiva should be pink and moist without redness, swelling, or discharge. Abnormal findings include pallor (anemia), redness (infection or irritation), or jaundice.