NCLEX-PN
Nclex Exam Cram Practice Questions Questions
Extract:
Question 1 of 5
A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?
Correct Answer: D
Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen to address the hypoxemia promptly and ensure the client's safety. Rechecking the pulse oximetry reading is important, but the priority is to address the hypoxemia by providing oxygen. Contacting the healthcare provider or respiratory therapist is not necessary at this time as the nurse can manage the hypoxemia with oxygenation. Oxygenating the client with 100% oxygen is the immediate action required in this situation.
Question 2 of 5
Correct Answer:
Rationale:
Question 3 of 5
Correct Answer:
Rationale:
Question 4 of 5
Correct Answer:
Rationale:
Question 5 of 5
Correct Answer:
Rationale: