The nurse receives a new prescription to administer oxygen at 3 L/minute via nasal cannula to maintain an oxygen saturation between 90 and 100% for a client. The nurse obtains an oxygen saturation reading of 85%, and after repositioning the oximeter on a different finger, obtains a second reading of 87%. Which action should the nurse take next?
Place the client in a Trendelenburg position.
Securely place the prongs of the cannula in the nostrils.
Place the pulse oximeter on the client's earlobe.
Document the second reading in the client's record.
The Correct Answer is B
Choice A reason: The Trendelenburg position is not indicated for increasing oxygen saturation and could be harmful, especially for clients with respiratory distress.
Choice B reason: Ensuring that the prongs of the nasal cannula are securely placed in the nostrils is important for effective oxygen delivery, especially if the oxygen saturation remains below the prescribed range.
Choice C reason: Placing the pulse oximeter on the client's earlobe is an alternative site for obtaining a saturation reading, but it does not address the issue of potentially inadequate oxygen delivery.
Choice D reason: While documentation is important, the nurse must first address the low oxygen saturation levels before documenting the readings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiced. Proceed with teaching the client how to walk with the crutches.
Choice A rationale:
Confer with the physical therapist for correct crutch size. This is unnecessary because the crutches are already correctly fitted.A space of three finger widths between the top of the crutch and the client’s axilla is appropriate to prevent pressure on the axilla and potential nerve damage.
Choice B rationale:
Ask the client to sit down while the crutch length is adjusted. This action is not needed since the crutches are already properly adjusted.Adjusting the crutch length further could lead to improper fitting, which might cause discomfort or injury.
Choice C rationale:
Assess the client for signs of diminished circulation in the hands. While assessing circulation is important, it is not directly related to the fitting of the crutches.Proper crutch fitting focuses on ensuring there is no pressure on the axilla and that the client can use the crutches comfortably.
Choice D rationale:
Proceed with teaching the client how to walk with the crutches. This is the correct action because the crutches are already properly fitted.The nurse should now focus on educating the client on the correct use of the crutches to ensure safe and effective mobility.
Correct Answer is D
Explanation
Choice A reason: Drinking 800 to 1,000 milliliters of fluid daily is below the recommended intake for most adults, which is generally around 2,000 milliliters per day to help prevent constipation.
Choice B reason: Oxycodone is an opioid that can actually lead to constipation, and its use should be carefully managed, not necessarily taken as scheduled for this purpose.
Choice C reason: Adding fat-containing foods is not a standard recommendation for preventing constipation; instead, a high-fiber diet is usually advised.
Choice D reason: Early and frequent ambulation is encouraged postoperatively to help stimulate bowel function and prevent constipation.
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