The nurse observes that the client’s pulse oximetry is 89%. What is the priority nursing action?

Perform respiratory assessment.

Document hypoxemia.

Check the placement of the pulse oximeter.

Report pulse oximetry to the health care provider.

Answer and Explanation

The Correct Answer is A

Pulse oximetry is a non-invasive method of monitoring the oxygen saturation level in the blood. A normal range for oxygen saturation is between 95% and 100%. An oxygen saturation level of 89% indicates hypoxemia, which is a serious condition that can lead to tissue damage, organ failure, and even death if left untreated.

Therefore, the priority nursing action is to perform a respiratory assessment to determine the cause of the hypoxemia. This should include assessing the client's airway patency, breathing patern, lung sounds, and oxygen therapy if the client is already receiving it. The nurse should also observe for any signs of respiratory distress such as cyanosis, accessory muscle use, or difficulty breathing.

While it is important to document hypoxemia and report it to the healthcare provider, the priority at this time is to assess and intervene promptly to prevent further deterioration of the client's condition. Checking the placement of the pulse oximeter may be necessary if the reading is unreliable, but it is not the priority in this scenario.

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Correct Answer is A

Explanation

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.

A. Hopefully this will help prevent her from getting pneumonia. B. The technique could help loosen secretions I may not have heard with my stethoscope. C. There is no need at this time to have chest physiotherapy at this time for this COPD patient. D. You can perform the technique after and before she eats lunch.

Correct Answer is B

Explanation

Chest physiotherapy can help loosen secretions that may not be audible with a stethoscope. This can help improve the patient’s breathing and overall lung function.

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The nurse observes that the client’s pulse oximetry is 89%. What is the priority nursing action?

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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