The nurse is obtaining a pulse oximetry reading for a client admited with exacerbation of chronic obstructive pulmonary disease (COPD). When observing a reading of 91%. what action should the nurse perform?

No action is required, because this may be normal for the client

The nurse should prepare intubation equipment for the health care provider

Administer oxygen at 6 L/m by nasal cannula

Have the client breath into a paper bag

Answer and Explanation

The Correct Answer is A

A. This is the most appropriate response. Clients with COPD often have chronically elevated carbon dioxide levels, which can lead to a compensatory decrease in the oxygen saturation level. A reading of 91% may be within their normal range.

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Correct Answer is B

Explanation

Fluid retention is a common complication in heart failure, and monitoring the client's ﬂuid status is crucial to manage the condition eﬀectively. Daily weights are an essential component of monitoring ﬂuid status and are the most sensitive and practical method to detect changes in the client's ﬂuid status. Weight gain is a reliable indicator of ﬂuid retention, and even small increases in weight can indicate the need for changes in the client's treatment plan.

Although electrolyte monitoring (option a), output measurements (option c), and daily BUN and serum creatinine monitoring (option d) can provide valuable information about the client's ﬂuid status, they are not as sensitive or practical as daily weights. Electrolyte monitoring can help detect changes in ﬂuid balance, but it does not provide a direct indication of ﬂuid status. Output measurements can indicate ﬂuid loss, but they do not provide an accurate assessment of ﬂuid retention. BUN and serum creatinine monitoring can detect changes in renal function, but they are not specific to ﬂuid status.

A. Chart the reading at 91%, this is normal for a COPD patient. B. Place a non-rebreather on the patient with high ﬂow oxygen. C. Call the doctor if the patient is declining. D. Sit the patient up and have them breathe deep.

Correct Answer is D

Explanation

Sitting the patient up and encouraging deep breathing can help improve oxygenation and increase the pulse oximetry reading. This is a non-invasive intervention that can be implemented immediately to help improve the patient’s oxygen levels.

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The nurse is obtaining a pulse oximetry reading for a client admited with exacerbation of chronic obstructive pulmonary disease (COPD). When observing a reading of 91%. what action should the nurse perform?

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Naxlex Comprehensive Predictor Exams

A client admited with heart failure requires careful monitoring of his ﬂuid status. Which method will provide the nurse with the best indication of the client’s ﬂuid status?

Correct Answer is B

Explanation

RH has a history of COPD. The CNA checks his vital signs at the beginning of the shift and tells you that his pulse ox reading is 91%. What should the nurse advise the CAN does next:

Correct Answer is D

Explanation

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