A Cardiovascular nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?
Toe.
Earlobe.
Skin fold.
Finger.
The Correct Answer is B
Choice A rationale:
Applying the pulse oximeter probe to the toe is not the most appropriate location. While toe measurements can be used, the fingers are more commonly used due to their accessibility and accuracy. Edema in the hands could affect the accuracy of readings.
Choice B rationale:
The nurse should apply the pulse oximeter probe to the earlobe. This choice is correct because the earlobe is a well-vascularized and easily accessible area that provides accurate oxygen saturation measurements. Thickened toenails and edema of the hands might compromise readings in those locations.
Choice C rationale:
Applying the pulse oximeter probe to a skin fold is not a recommended site for oxygen saturation measurement. While there are various sites where pulse oximeters can be applied, the earlobe and finger are more suitable due to their consistent blood flow and accessibility.
Choice D rationale:
While applying the pulse oximeter probe to the finger is a common and acceptable practice, in this scenario, edema of the hands could affect the accuracy of the readings. The earlobe is a better choice as it is less likely to be affected by edema and can provide accurate readings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale:
Drowsiness alone may not be a reliable indicator of pain, as it can result from various factors such as medications or the postoperative recovery process. While pain might cause drowsiness in some cases, it is not a definitive nonverbal sign of pain.
Choice B rationale:
Grimacing is a nonverbal behavior that often indicates pain or discomfort. It involves facial expressions of pain, such as frowning or wincing. Grimacing is a significant indicator that the nurse should consider in assessing the client's pain level.
Choice C rationale:
Screaming is a more overt expression of pain and discomfort. However, it is less common in a postoperative setting and might also be associated with anxiety or other emotional states. While it can indicate pain, it's not as reliable a marker as grimacing, moaning, or restlessness.
Choice D rationale:
Moaning is a nonverbal behavior that can signal pain in a postoperative client. It's an audible expression of discomfort and should be considered as a potential indication of pain.
Choice E rationale:
Restlessness can be an indication of pain as well. The client may shift positions frequently or exhibit signs of agitation in response to pain. However, restlessness can also have other causes, such as anxiety or medication effects.
Correct Answer is B
Explanation
Choice A rationale:
Using an internet webpage translator might seem convenient, but it can lead to inaccuracies in communication due to language nuances and medical terminology. Direct communication with a human translator is more reliable.
Choice B rationale:
Arranging to complete the assessment with only the client and a translator present is the best option. This approach ensures accurate and confidential communication, allowing the nurse to gather essential information directly from the client without potential bias or misinterpretation from family members.
Choice C rationale:
Asking the client's husband to translate questions and answers for the client can lead to inaccurate or biased information. Additionally, it might not provide a safe environment for the client to openly share her concerns.
Choice D rationale:
Asking a male student nurse to translate for the client does not necessarily address the language barrier adequately. The gender of the translator is not the primary concern here. Ensuring effective communication through a professional translator is more important.
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