When measuring the client's pulse oximetry you find the client to have a reading of 85%, down from 92% 1 hour ago. Which action should you perform first?
A. Administer oxygen by mask or cannula.
B. Document the finding.
C. Verify the measurement.
D. Notify the physician.
C
A pulse oximetry reading in this range indicates desaturation and is considered an emergency requiring immediate intervention. However, the nurse should first verify the accuracy of the reading by measuring pulse oximetry at another body site (nose, earlobe, or forehead). If the measurement shows desaturation at the second site, administer oxygen and notify the physician.
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A patient who underwent carotid endarterectomy is being discharged from the CCU. Which of the following instructions should the nurse give to the patient?
A) Avoid rotating your head. B) Bruising and discoloration of the neck are not normal and should be reported immediately. C) Eat a low-fat diet. D) Avoid washing the incision site.
The school nurse completes an assessment of a 6-year-old child to determine the services the child will need in the classroom. The child needs respiratory support with oxygen
The child also requires enteral tube feedings and intravenous medication during the school day. With these needs, the school nurse evaluates the child to be: 1. Developmentally delayed. 2. Mentally handicapped. 3. Socially withdrawn. 4. Medically fragile.
An African-American woman noticed some bruised-looking areas on her baby's buttocks. She asked the nurse if the baby was spanked at birth. The nurse explains that these marks are referred to as:
A. mongolian spots. B. harlequin color change. C. nevus flammeus. D. mottling.
Which statement about multivitamins is accurate?
a. Multivitamins are essential organic micronutrients the body needs in small amounts for various roles throughout the human body. b. Multivitamins are essential micronutrients which are inorganic elements. c. Multivitamins are preparations that contain several vitamins essential for health. d. Multivitamins are only water soluble vitamins and trace minerals.