Hesi RN Fundamentals of Nursing
Hesi RN Fundamentals of Nursing ( 44 Questions)
The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?
Switching to a non-rebreather mask is not appropriate for this client. A non-rebreather mask delivers a high concentration of oxygen (up to 100%) and is used for clients who are critically ill or have very low oxygen saturation levels. This client has a mild hypoxemia and does not need such a high flow of oxygen.
Removing the nasal cannula is not advisable for this client. The client is postoperative and may have impaired gas exchange due to anesthesia, pain, or decreased mobility. Removing the supplemental oxygen may worsen the client's hypoxemia and increase the risk of complications.
Increasing the oxygen to 3 L/minute is the best action for this client. The client has a mild hypoxemia (normal oxygen saturation is 95% or higher) and may benefit from a slight increase in oxygen delivery. A nasal cannula can deliver oxygen at a low flow rate (1 to 6 L/minute) and is suitable for clients who are stable and need mild to moderate oxygen therapy.
Verifying the placement of the pulse oximeter is not a priority for this client. The pulse oximeter measures the oxygen saturation of hemoglobin in arterial blood by using a sensor attached to the finger, toe, earlobe, or forehead. The placement of the sensor may affect the accuracy of the reading, but it is not likely to cause a significant change in the oxygen saturation level. The nurse should verify the placement of the pulse oximeter after increasing the oxygen flow rate and reassessing the client's condition.
No explanation
Choice A: Switching to a non-rebreather mask is not appropriate for this client. A non-rebreather mask delivers a high concentration of oxygen (up to 100%) and is used for clients who are critically ill or have very low oxygen saturation levels. This client has a mild hypoxemia and does not need such a high flow of oxygen.
Choice B: Removing the nasal cannula is not advisable for this client. The client is postoperative and may have impaired gas exchange due to anesthesia, pain, or decreased mobility. Removing the supplemental oxygen may worsen the client's hypoxemia and increase the risk of complications.
Choice C: Increasing the oxygen to 3 L/minute is the best action for this client. The client has a mild hypoxemia (normal oxygen saturation is 95% or higher) and may benefit from a slight increase in oxygen delivery. A nasal cannula can deliver oxygen at a low flow rate (1 to 6 L/minute) and is suitable for clients who are stable and need mild to moderate oxygen therapy.
Choice D: Verifying the placement of the pulse oximeter is not a priority for this client. The pulse oximeter measures the oxygen saturation of hemoglobin in arterial blood by using a sensor attached to the finger, toe, earlobe, or forehead. The placement of the sensor may affect the accuracy of the reading, but it is not likely to cause a significant change in the oxygen saturation level. The nurse should verify the placement of the pulse oximeter after increasing the oxygen flow rate and reassessing the client's condition.