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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
AB+ blood type is known as the universal recipient because individuals with this blood type have both A and B antigens on the surface of their red blood cells, as well as the Rh antigen. This means that they can receive blood from donors of any ABO blood type (A, B, AB, or O) and Rh factor (positive or negative) without experiencing a transfusion reaction.
Therefore, in the case of a patient who will be needing a blood transfusion, if the nurse knows that the patient's blood type is unknown, it is ideal to give them AB+ blood type as it is considered the safest option.
Correct Answer is A
Explanation
The use of an incentive spirometer is essential after surgery to prevent complications such as pneumonia and atelectasis. Atelectasis is the collapse of air sacs in the lungs, which can occur after surgery due to decreased respiratory effort and shallow breathing. An incentive spirometer helps the patient take deep breaths and increase their lung volume, preventing these complications.
Breathing rapidly to prevent pneumonia (option b) is not recommended as it can lead to hyperventilation and other respiratory complications.
Option c is incorrect because patient education is a crucial aspect of post-operative care, and the patient needs to be aware of the potential complications and how to prevent them.
The use of a chest tube (option d) is not usually required after hip surgery, and it is not a priority teaching for the patient.
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