Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse has obtained a client's oxygen saturation measurement of 88% on 2 liters of oxygen via nasal cannula. Which of the following actions should the nurse take?
A. Check the client's heart rate on the oximeter
A. Check the client's heart rate on the oximeter: Although checking the heart rate may provide context for assessing the client's overall status, it does not address the primary concern of the low oxygen saturation. Understanding the client's baseline saturation level takes priority to guide further actions effectively.
B. Compare the result with the baseline reading
B. Compare the result with the baseline reading: Comparing the reading with the client's baseline is essential. For clients with chronic respiratory conditions, baseline oxygen levels may naturally be lower. Identifying if this 88% saturation is typical or unusual for the client helps determine the need for further intervention or adjustment.
C. Decrease the amount of oxygen administered
C. Decrease the amount of oxygen administered: Reducing oxygen flow when the saturation is low is contraindicated, as it could worsen hypoxia. Instead, increasing oxygen may be warranted if the reading remains below the baseline after further assessment.
D. Perform another reading while the client ambulates
D. Perform another reading while the client ambulates: Repeating the reading during ambulation may worsen hypoxia and is not ideal without understanding baseline oxygenation at rest. Re-evaluation at rest or in a different position may be more appropriate for accurate assessment.
This question is an excerpt from Nurse Dive's nursing test bank - VATI PN Comprehensive Predictor 2020 Proctored Exam. Take the full exam now
Full Explanation
Answer: B. Compare the result with the baseline reading
Rationale:
A. Check the client's heart rate on the oximeter:
Although checking the heart rate may provide context for assessing the client's overall status, it does not address the primary concern of the low oxygen saturation. Understanding the client's baseline saturation level takes priority to guide further actions effectively.
B. Compare the result with the baseline reading:
Comparing the reading with the client's baseline is essential. For clients with chronic respiratory conditions, baseline oxygen levels may naturally be lower. Identifying if this 88% saturation is typical or unusual for the client helps determine the need for further intervention or adjustment.
C. Decrease the amount of oxygen administered:
Reducing oxygen flow when the saturation is low is contraindicated, as it could worsen hypoxia. Instead, increasing oxygen may be warranted if the reading remains below the baseline after further assessment.
D. Perform another reading while the client ambulates:
Repeating the reading during ambulation may worsen hypoxia and is not ideal without understanding baseline oxygenation at rest. Re-evaluation at rest or in a different position may be more appropriate for accurate assessment.
Similar Questions
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following actions by the nurse demonstrates cost-effective care?
A. Flexes the client's affected hip to 120
B. Adducts the client's affected leg
C. Checks the neurovascular status of the client's lower extremities every 6 hr
D. Applies a sequential compression device to the client's lower extremities
Applying a sequential compression device to the client's lower extremities demonstrates cost-effective care. This intervention helps prevent venous thromboembolism (VTE) and is a cost-effective method compared to other measures like administering prophylactic anticoagulation medications or performing Doppler studies. Flexing the client's affected hip to 120 (option a) and adducting the affected leg (option b) are specific positioning techniques for a total hip arthroplasty but do not directly address cost- effectiveness. Checking the neurovascular status every 6 hours (option c) is important for postoperative monitoring but does not specifically demonstrate cost-effective care in this context.
A nurse is preparing to administer medication to a child through an enteral tube. Which of the following actions should the nurse take after administering the medication?
A. Flush the tubing.
After administering medication through an enteral tube, the nurse should flush the tubing to ensure that the medication is fully delivered and to prevent any residual medication from clogging the tube. Flushing the tubing with an appropriate amount of water helps ensure that the medication reaches the desired location and prevents any potential blockages. Clamping the tubing (option b) is not necessary after medication administration and may interfere with the flow of fluids or other medications. Checking patency of the tubing (option c) may be done before medication administration but is not specifically related to actions after medication administration. Aspirating the tubing (option d) is not required unless specifically indicated for certain medications or circumstances.
B. Clamp the tubing
C. Check patency of the tubing
D. Aspirate the tubing
A nurse is assisting in the care of a client who is experiencing a postpartum hemorrhage.
Which of the following medications should the nurse plan to administer?
A. Terbutaline
Is a medication used for the management of preterm labor by relaxing the uterine smooth muscles. It is not indicated for postpartum hemorrhage.
B. Methylergonovine
Postpartum hemorrhage is a significant complication that can occur after childbirth. Methylergonovine is a medication commonly used to manage postpartum hemorrhage. It is an ergot alkaloid that helps to contract the uterus, reducing bleeding. It is typically administered either intramuscularly or orally. It's important to note that the specific management of postpartum hemorrhage may vary depending on the underlying cause, severity of bleeding, and individual patient factors. The healthcare provider will determine the most appropriate interventions and medications for each case.
C. Magnesium sulfate
Is a medication used for the prevention and treatment of seizures in patients with preeclampsia or eclampsia. It is not specifically indicated for postpartum hemorrhage.
D. Nifedipine
Is a calcium channel blocker commonly used to manage hypertension. It is not indicated for postpartum hemorrhage.
Full Explanation
b. Methylergonovine.
Explanation:
Postpartum hemorrhage is a significant complication that can occur after childbirth. Methylergonovine is a medication commonly used to manage postpartum hemorrhage. It is an ergot alkaloid that helps to contract the uterus, reducing bleeding. It is typically administered either intramuscularly or orally.
Option a, Terbutaline, is a medication used for the management of preterm labor by relaxing the uterine smooth muscles. It is not indicated for postpartum hemorrhage.
Option c, Magnesium sulfate, is a medication used for the prevention and treatment of seizures in patients with preeclampsia or eclampsia. It is not specifically indicated for postpartum hemorrhage.
Option d, Nifedipine, is a calcium channel blocker commonly used to manage hypertension. It is not indicated for postpartum hemorrhage.
It's important to note that the specific management of postpartum hemorrhage may vary depending on the underlying cause, severity of bleeding, and individual patient factors. The healthcare provider will determine the most appropriate interventions and medications for each case.
