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 C
Explanation
Choice A reason: This is not the correct answer because infant bones are not prone to fractures. They are more flexible and resilient than adult bones, and require more force to break.
Choice B reason: This is not the correct answer because the focus should not be only on the injury, but also on how it occurred. The nurse should assess the mechanism of injury and the history of the child and the family for any signs of abuse or neglect.
Choice C reason: This is the correct answer because inconsistencies in how injury occurred may indicate child maltreatment. The nurse should be alert for any discrepancies or changes in the story, or any explanations that do not match the type or severity of the injury.
Choice D reason: This is not the correct answer because parents don't necessarily forget details when they are under stress. They may be anxious or emotional, but they should still be able to provide a consistent and coherent account of what happened.
Correct Answer is B
Explanation
Choice A reason: This is not appropriate because it implies that the child's current diet is inadequate or incompatible with diabetes management. It may also offend the parents and the child by disregarding their cultural and religious preferences.
Choice B reason: This is appropriate because it shows respect and sensitivity for the child's and the parents' dietary choices. It also helps the nurse to tailor the dietary education and advice according to the child's needs and preferences.
Choice C reason: This is not appropriate because it contradicts the child's and the parents' beliefs and practices. Hindus consider fruit to be sacred and offer it to their gods. They do not eat fruit after it has been offered, as it is considered prasad, or blessed food.
Choice D reason: This is not appropriate because it assumes that meat is the only or the best source of protein. It may also violate the child's and the parents' ethical or religious values, as some Hindus avoid meat or certain types of meat.
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