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","B","C","D","E"]

Explanation

A tracheostomy is a surgical procedure that involves creating an opening in the neck to establish a direct airway to the trachea. It is usually done in patients who require long-term mechanical ventilation or have upper airway obstruction. In case the tracheostomy becomes dislodged, the following equipment should be available to ensure the patient's safety:

Tracheostomy kit setup: This includes a new tracheostomy tube, obturator, and other equipment necessary to replace the dislodged tracheostomy tube.

Suction equipment: Dislodgement of the tracheostomy tube can cause airway obstruction due to the presence of secretions. Suction equipment can be used to remove the secretions and prevent airway obstruction.

Smaller Tracheostomy Tube and Same size Tracheostomy Tube: If the dislodged tracheostomy tube cannot be reinserted or is damaged, having smaller and same size tracheostomy tubes available can be helpful in establishing a new airway.

Ambu bag: This is a manual resuscitation device used to provide positive pressure ventilation to the patient. It can be used in case the patient's breathing is compromised due to airway obstruction.

Oxygen: The patient may require supplemental oxygen if their breathing is compromised due to airway obstruction.

Larger Tracheostomy Tube: A larger tracheostomy tube may not be needed immediately and may be contraindicated in some cases as it can cause trauma to the tracheal wall.

A. Respiratory acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Metabolic acidosis

Correct Answer is A

Explanation

A. Respiratory acidosis.

COPD is a chronic lung disease that can lead to an accumulation of carbon dioxide (CO2) in the body. This can cause respiratory acidosis, a condition in which the blood pH is lower than normal due to an excess of CO2.

In respiratory acidosis, the partial pressure of carbon dioxide (PaCO2) in the blood is increased and the pH is decreased. The kidneys atempt to compensate for the acidosis by excreting more acid in the urine and retaining more bicarbonate, but this compensation is usually not enough to fully correct the problem.

Metabolic alkalosis (option B) is a condition in which the blood pH is higher than normal due to an excess of bicarbonate in the blood. This is usually caused by loss of acid from the body, such as through vomiting or use of diuretics.

Respiratory alkalosis (option C) is a condition in which the blood pH is higher than normal due to a decrease in PaCO2. This can be caused by hyperventilation, which leads to excessive elimination of CO2 from the lungs.

Metabolic acidosis (option D) is a condition in which the blood pH is lower than normal due to an excess of acid in the blood. This can be caused by a variety of factors, including kidney failure or lactic acidosis.

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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

You are setting up a room for your patient that has a new tracheostomy. Select all of the equipment you need bring with to ensure patient is safe should the tracheostomy become dislodged:

Correct Answer is ["A","B","C","D","E"]

Explanation

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which arterial blood gas data does the nurse anticipate finding in this patient?

Correct Answer is A

Explanation

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