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 C
Explanation
Choice A reason: Giving water may be necessary, but it is not the first intervention if there is a concern about urinary output.
Choice B reason: Notifying the healthcare provider is important but should occur after initial assessments and interventions.
Choice C reason: Checking for a kink in the drainage tubing is a quick and simple intervention that may resolve the issue of low output.
Choice D reason: Reviewing the intake and output record is important for understanding the patient's fluid status but is not the first action to take in this situation.
Correct Answer is D
Explanation
Choice A reason: Dizziness is not typically associated with perineal care and is not relevant to the instructions.
Choice B reason: Advising to keep the pubic area shaved is not a standard part of perineal care instructions and is a personal choice.
Choice C reason: The statement about not retracting the foreskin is incorrect; the foreskin should be retracted gently for cleaning and then returned to its normal position to prevent infection.
Choice D reason: It is important to inform the caregiver that an erection may occur as a natural reflex during perineal care, and it does not indicate any sexual intent. This helps prepare the caregiver to handle the situation professionally.
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