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 Instruct a staff member to get the electrocardiogram machine.2 Call for a portable stat chest x-ray.3 Have a staff member notify the nursing supervisor of the change in client status.4 Notify the healthcare provider of the change in the oxygen saturation.5 Tell the certified nursing assistant to get a prescription from the healthcare provider to increase the oxygen.6 Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4 L nasal cannula.

Answer 1

Answer: number 1, 2, 3 and 6 actions are correct

Explanation:

A staff member can get the electrocardiogram machine and get procedure done even if they are not able to interpret the result, because ancillary personnel are trained to do electrocardiograms. Anyone can notify the x-ray department that the chest x-ray must be done. It is important to delegate this tasks to a specific person.

Increasing the oxygen without a prescription is appropriate in the short term is possible, but the nurse must obtain a prescription when notifying the health care provider. Notifying the health care provider of the change in oxygen saturation is appropriate, but it would be expected that nursing judgment had taken place and the oxygen already was increased from 2 L/min. Telling the certified nursing assistant (CNA) to get a prescription is a great action as a CNA is not allowed to take medical prescriptions (it's a nursing role)