Question

The primary healthcare provider has prescribed a stat chest x-ray exam and electrocardiogram for a client with a history of heart failure. The pulse oximeter has changed from 90% to 86% oxygen saturation. Which immediate actions will the nurse take? Select all that apply.1. Tell a staff member to get the electrocardiogram machine.

2. Notify the x-ray department that a chest x-ray must be done stat.
3. Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4 L nasal cannula and notify the health care provider.
4. Have a staff member notify the nursing supervisor of the change in client status.
5. Notify the health care provider of the change in the oxygen saturation to ask what to do.
6. Tell the certified nursing assistant to get a prescription from the health care provider to increase the oxygen

Answer 1

1 ✔

Tell a staff member to get the electrocardiogram machine.

2✔

Notify the x-ray department that a chest x-ray must be done stat.

3✔

Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4 L nasal cannula and notify the health care provider.

4✔

Have a staff member notify the nursing supervisor of the change in client status.

5❌

Notify the health care provider of the change in the oxygen saturation to ask what to do.

6❌

Tell the certified nursing assistant to get a prescription from the health care provider to increase the oxygen

Step-by-step explanation:

1✔

Tell a staff member to get the electrocardiogram machine.

A staff member can be asked to get the electrocardiogram machine and to begin the procedure. An Ancillary personnel can also be called for this as they are taught to do electrocardiograms even if they find it difficult to explain the results.

2✔

Notify the x-ray department that a chest x-ray must be done stat.

It's necessary for somebody to notify the x-ray department of the need to have the chest x-ray carried out. It is necessary to assign the tasks to a certain person.

3✔

Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4 L nasal cannula and notify the health care provider.

Increasing the oxygen without a prescription is permitted in the short term, but there is need for the nurse to still get a prescription when informing the health care provider.

4✔

Have a staff member notify the nursing supervisor of the change in client status.

It's appropriate to have a staff member notify the nursing supervisor of the change in client status.

5❌

Notify the health care provider of the change in the oxygen saturation to ask what to do.

Notifying the health care provider of the change in oxygen saturation is necesaary, but it is believed that nursing judgment would have been done and the oxygen would have been increased from 2 L/min.

6❌

Tell the certified nursing assistant to get a prescription from the health care provider to increase the oxygen

Telling the certified nursing assistant (CNA) to get a prescription is an wrong as a CNA is not permitted to collect medical prescriptions as its the duty of a nursing role.