While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

Complete the intermittent suction of the nasopharynx.

Apply an oxygen mask over the client's nose and mouth.

Reposition the pulse oximeter clip to obtain a new reading.

Stop suctioning until the pulse oximeter reading is above 95%.

Answer and Explanation

The Correct Answer is A

Choice A reason: If the oxygen saturation remains stable during the procedure, it indicates that the suctioning is not adversely affecting the client's oxygenation, and the nurse can safely continue.

Choice B reason: Applying an oxygen mask is not necessary if the oxygen saturation is stable and within a safe range.

Choice C reason: Repositioning the pulse oximeter clip is only necessary if there is a concern about the accuracy of the reading, not when the reading is stable.

Choice D reason: There is no need to stop suctioning if the oxygen saturation is stable at 94%, as this is within the acceptable range for most clients.

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Correct Answer is C

Explanation

Choice A reason: Offering positive reinforcement is a good practice in teaching, but it does not directly facilitate the learning of problem-solving strategies.

Choice B reason: Physical demonstrations are more suited to teaching psychomotor skills rather than problem-solving strategies.

Choice C reason: Simulation activities allow individuals to practice problem-solving in a controlled environment, which can enhance learning and retention of these strategies.

Choice D reason: Verbal analogies can aid in understanding concepts, but they are less interactive and engaging than simulation activities when it comes to learning problem-solving strategies.

A. Explain that since the medication is a controlled substance, it must be taken. B. Credit the medication back and put it in the client's medication box. C. Keep the medication and see if the client will want to take it later. D. Have another nurse witness the disposal of the medication into the disposal container.

Correct Answer is D

Explanation

Choice A reason: The nurse cannot force the client to take medication against their will, even if it is a controlled substance.

Choice B reason: Crediting the medication back and placing it in the client's medication box is not appropriate as the medication has already been removed from the unit dose wrapper.

Choice C reason: Keeping the medication to see if the client will want to take it later is not safe practice as it could lead to medication errors or misuse.

Choice D reason: The nurse should dispose of the medication properly, and having another nurse witness the disposal is a standard procedure to ensure that controlled substances are accounted for.

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While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

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