When taking vital signs, a nurse notes that a client's oxygen saturation is 89%. What should the nurse do next?
Increase the client's oxygen flow rate.
Check the client's temperature.
Document the findings and continue with care.
Assess the client's pain level.
The Correct Answer is A
A. An oxygen saturation of 89% is below the normal range (typically 95–100%) and indicates hypoxemia. The nurse should immediately take action to improve oxygenation, such as increasing the oxygen flow rate as prescribed or notifying the provider if adjustments are needed.
B. Checking the client’s temperature is unrelated to acute low oxygen saturation and does not address the immediate risk of hypoxia.
C. Simply documenting the findings without intervention could allow the client’s oxygen levels to worsen, putting them at risk for organ dysfunction.
D. Assessing pain is important for overall care, but it does not address the urgent need to correct low oxygen saturation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Applying a moisturizing lotion may help maintain skin integrity but does not address the immediate risk of pressure injury.
B. Repositioning the client to alleviate pressure is the priority action. Reddened areas on bony prominences, such as the sacrum, indicate early signs of pressure injury, and relieving pressure prevents further tissue damage.
C. Continuing with the hygiene routine and reassessing later delays intervention, increasing the risk of progression to a pressure ulcer.
D. Documenting the finding is important, but it is not the first action; immediate interventions to reduce pressure must take precedence to protect skin integrity.
Correct Answer is A
Explanation
A. The length of time spent washing hands is the most important factor in effective hand hygiene. Proper technique with adequate duration (at least 20 seconds with soap and water or until hand rub dries) ensures removal of pathogens and reduces the risk of infection transmission.
B. While the type of soap or hand rub matters, standard non-antibacterial soap is generally sufficient if proper technique and time are used; the duration and thoroughness are more critical.
C. Using antibacterial soap is not required for routine hand hygiene and does not significantly improve effectiveness over regular soap with proper technique.
D. Water temperature does not significantly impact the removal of pathogens; it mainly affects comfort. Effective hand hygiene relies on mechanical friction and adequate washing time, not water temperature.
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