You enter a two-year-old patient's room and see the pulse oximeter reading 55% oxygen saturation. Your first action would be to:
Call the physician.
Place the patient on 10 L/min oxygen per nasal cannula.
Assess the patient.
Administer oxygen and monitor vital signs while calling the physician.
The Correct Answer is D
Choice A reason: Calling the physician is not the first action because it would delay the immediate intervention of oxygen administration, which is critical for a patient with hypoxia. The physician should be notified after initiating oxygen therapy and assessing the patient's condition.
Choice B reason: Placing the patient on 10 L/min oxygen per nasal cannula is not the first action because it is too high of a flow rate for a two-year-old patient, and it could cause oxygen toxicity or barotrauma. The appropriate oxygen delivery device and flow rate should be determined based on the patient's age, weight, and clinical status.
Choice C reason: Assessing the patient is not the first action because it would also delay the immediate intervention of oxygen administration. The patient's pulse oximetry reading indicates severe hypoxia, which requires prompt treatment to prevent organ damage or death. The patient should be assessed after initiating oxygen therapy and monitoring vital signs.
Choice D reason: Administering oxygen and monitoring vital signs while calling the physician is the correct answer because it provides the most effective and timely response to the patient's hypoxia. Oxygen administration improves the patient's oxygen saturation and tissue perfusion, while vital sign monitoring helps to evaluate the patient's response to therapy and identify any complications. Calling the physician informs them of the situation and allows them to order further interventions or tests as needed.
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This situation does not require the involvement of the hospital ethics committee, as the parents are not refusing or requesting any treatment that is contrary to the standard of care. The surgeon is providing them with information and options, and the parents are free to make their own decision.
Choice B reason: This situation does not involve any ethical dilemma, as the parents are giving their permission for the surgery, and the telephone consent is legally valid. The hospital ethics committee is not needed to resolve any conflict or uncertainty.
Choice C reason: This situation is an example of ethical research involving children, as the child is giving assent and the parents are giving consent for the new protocol. The hospital ethics committee is not required to intervene, as the research protocol has already been approved by the institutional review board.
Choice D reason: This situation is an appropriate case for the hospital ethics committee, as it involves a life-and-death decision that affects the child's best interests and the parents' rights. The hospital ethics committee can help to mediate the conflict, provide guidance, and facilitate a resolution.
Correct Answer is D
Explanation
Choice A reason: The child's current vital signs are not a reliable indicator of pain, as they may vary depending on the child's condition, medication, and stress level. Vital signs alone are not sufficient to assess pain in children.
Choice B reason: The child becoming quiet when held and cuddled may indicate that the child is comforted by the nurse's presence and touch, not that the child is in pain. In fact, some children may become more vocal and restless when they are in pain.
Choice C reason: The child having just returned from the recovery room does not necessarily mean that the child is in pain. The child may have received pain medication during or after the surgery, or the child may have a different pain threshold. The nurse should not assume that the child is in pain based on the procedure alone.
Choice D reason: The child lying rigidly in bed and not moving is a sign of pain in children, as they may try to avoid movement that could aggravate their pain. The child may also exhibit facial expressions, such as grimacing, frowning, or clenching their teeth, that indicate pain. The nurse should assess the child's pain level and administer pain medication as ordered.
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