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    Vati PN Comprehensive Predictor Proctored Exam

    A nurse has obtained a client's oxygen saturation measurement of 88% on 2 liters of oxygen via nasal cannula. Which of the following actions should the nurse take?

    Explanation & Rationale

    A. Check the client's heart rate on the oximeter: While the oximeter displays heart rate, this action does not address the primary concern of hypoxemia. Heart rate alone cannot determine whether the client’s oxygenation is adequate or if further intervention is needed. B. Compare the result with the baseline reading: Comparing the current SpO2 of 88% with the client’s baseline oxygen saturation helps determine the severity of hypoxemia and guides clinical decisions. This step is essential before adjusting oxygen therapy or notifying the provider, ensuring interventions are appropriate and individualized. C. Decrease the amount of oxygen administered: Reducing supplemental oxygen in a client with a saturation of 88% would worsen hypoxemia and risk tissue hypoxia. Oxygen titration should aim to maintain safe saturation levels, usually above 92% for most adults, unless otherwise prescribed. D. Perform another reading while the client ambulates: Ambulating may further decrease oxygen saturation in a hypoxemic client and does not provide useful information before addressing the low SpO2. Assessment and stabilization should occur first to prevent adverse events.

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