Practice Quiz

NCLEX-RN

Category - Reduction of Risk

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A nurse is checking the oxygen saturation of the client, who was just transferred from PACU after an abdominal surgery. The pulse oximeter reads 87%. The client’s vital signs are within normal range. What is the best action of the nurse?
  1. Recheck the oxygen saturation after 15 minutes.
  2. Recheck the vital signs.
  3. Administer PRN oxygen to this client.
  4. Re-attach the pulse oximeter to another site.
Explanation
Answer: D - The probe should be removed and re-attached at another finger or earlobe to verify the reading. The probe sensor is sensitive to changes in temperature and vascularity of the site where it is attached. Normal O2 saturation is between 95-100%. Less than 85% indicates that the tissue is not receiving enough oxygen. If the reading remains the same PRN oxygen should be given to increase ventilation, and vital signs taken for further evaluation of respiratory status.
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