The nursing assistant reports to the nurse that an African-American client's pulse oximetry reading is 93%. The client has no complaints. Which action by the nurse is most appropriate?
a. Replace the sensor probe of the oximeter.
b. Place the probe on another finger.
c. Assess other signs of respiratory adequa-cy.
d. Prepare to obtain arterial blood gases.
C
Normal pulse oximetry readings are 95% to 100%. However, people with dark skin can have readings that are 3% to 5% lower owing to the darker coloration of the nail bed. The nurse should assess other signs of respiratory adequacy because this may be a normal finding for this client.
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The physical changes of menopause are the result of:
a. Lowered estrogen level b. Increased progesterone c. Loss of phosphorus from the bones d. Inactivity and loss of muscle tone
The client is prescribed enalapril (Vasotec) as treatment for heart failure. Which is the priority nursing assessment following the initial administration of this drug?
1. Assess the client for an irregular pulse. 2. Assess the client's blood pressure. 3. Assess the client for ototoxicity. 4. Assess the client for a serious rash.
The normal respiratory rate is determined by age.
Answer the following statement true (T) or false (F)
The nurse is caring for a patient with a history of left-sided congestive heart failure (CHF). Which finding leads the nurse to suspect that the patient could be experiencing an acute exacer-bation of this condition?
a. The abdomen is tight and shiny. b. Wheezes are present during lung ausculta-tion. c. The pupils react sluggishly to light. d. The heart rate is irregularly irregular.