Practice Question
A nurse caring for a child who is receiving oxygen therapy and is on a continuous oxygen saturation monitor that is reading 89%. Which of the following actions should the nurse take first?
Answer Choices:
Correct Answer:
Ensure proper placement of the sensor probe.
Rationale:
🌟 When a child’s continuous pulse oximeter reads 89%, the nurse should first consider whether the reading is accurate before making treatment changes.
🌟 Improper probe placement, motion, poor perfusion, or loose sensors can cause false low readings, leading to unnecessary interventions.
🌟 The principle “assess before you act” guides the nurse to check equipment and placement prior to adjusting oxygen or adding interventions.
🌟 Confirming correct site, snug fit, and good waveform ensures the SpO₂ reading truly reflects the child’s oxygenation status.
🌟 Only after verifying that the probe is properly placed should the nurse proceed to other actions if the saturation remains low.
Increase the oxygen flow rate.
🌟 Increasing the oxygen flow rate may be appropriate if a true hypoxemia is confirmed, but doing so before verifying the accuracy of the reading risks unnecessary oxygen therapy.
🌟 Oxygen is a medication, and changes to flow rate should follow assessment and orders, not be based solely on a potentially inaccurate monitor reading.
🌟 Without ensuring that the probe is correctly placed, the nurse may be reacting to an artifact rather than a real physiological problem.
🌟 This undermines safe practice and can mask underlying issues like poor perfusion, technical malfunction, or displacement of the probe.
🌟 Because assessment should come first, this is not the first action, even if it may be needed later.
Place the child in the Fowler's position.
🌟 Placing the child in Fowler’s or semi-Fowler’s position can facilitate lung expansion and is a common intervention in respiratory distress.
🌟 However, in this scenario, the low saturation may be due to equipment issues rather than a change in the child’s actual respiratory status.
🌟 If the monitor reading is inaccurate, changing the position does not address the fundamental question: “Is this number real?”
🌟 Nursing process requires validating the data (checking the probe) before altering the child’s position specifically in response to the reading.
🌟 Therefore, while Fowler’s can be helpful, it is not the first priority before verifying sensor placement.
Encourage the child to take deep breaths.
🌟 Encouraging deep breathing can help improve ventilation and oxygenation, particularly if shallow breathing is an issue.
🌟 But this assumes the oxygen saturation reading reflects actual hypoxia, which has not yet been confirmed.
🌟 The child might already be adequately oxygenated, and the low reading could be due to a misplaced probe or technical artifact.
🌟 Jumping to patient-directed interventions without confirming accurate data can lead to misdirected efforts and confusion.
🌟 Consequently, this is not the first nursing action—equipment assessment takes priority.
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This question is from Custom PNSG Respiratory Cardiac Exam Fall 2025 which contains 42 questions.
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From Exam
Custom PNSG Respiratory Cardiac Exam Fall 2025
42 Questions
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- Category: LPN Nursing Exam(s)
- Subcategory: LPN ATI Exams
- Domain: 💫PN Custom Exam(s)
- Answer Choices: 4