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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is choice A. Transparent dressing.

Choice A rationale:

Transparent dressings are appropriate for stage I pressure ulcers. These dressings provide a moist environment that promotes healing and protects the wound from external contaminants. They are also transparent, allowing the nurse to monitor the wound without removing the dressing. As stage I pressure ulcers involve intact skin with non-blanchable redness, these dressings aid in preventing friction and shear forces that could exacerbate the injury.

Choice B rationale:

Alginate dressings (Choice B) are not suitable for stage I pressure ulcers. Alginate dressings are highly absorbent and are generally used for wounds with moderate to heavy exudate, such as infected wounds or those with necrotic tissue. They may not be the best choice for a stage I pressure ulcer, which is characterized by superficial skin involvement without exudate or necrosis.

Choice C rationale:

Hydrogel dressings (Choice C) are beneficial for wounds with minimal to no exudate, but they are more appropriate for partial-thickness wounds, burns, or dry wounds. They provide a moist environment and promote autolytic debridement. However, in the case of a stage I pressure ulcer, where the skin is intact and there is no exudate, hydrogel dressings may not be the ideal choice.

Choice D rationale:

Wet-to-dry gauze dressings (Choice D) involve placing moist saline gauze onto a wound bed and allowing it to dry before removal. This method is used for mechanical debridement of wounds with necrotic tissue, and it's not suitable for a stage I pressure ulcer. In fact, using wet-to-dry dressings on a superficial wound could cause trauma and hinder healing.

A. Drowsiness. B. Jaundice. C. Flushed pink cheeks. D. Tachycardia.

Correct Answer is D

Explanation

Choice A rationale:

Drowsiness is not a typical finding associated with hypoxia. Hypoxia often leads to increased alertness and anxiety as the body tries to compensate for the lack of oxygen. Drowsiness might be seen in severe cases of hypoxia, but it's not a consistent finding.

Choice B rationale:

Jaundice is not directly related to hypoxia. Jaundice is usually caused by elevated bilirubin levels due to liver dysfunction or other underlying issues. It is not a primary manifestation of hypoxia.

Choice C rationale:

Flushed pink cheeks can be an indicator of increased blood flow to the skin, which might occur as the body tries to compensate for hypoxia. However, this finding is not as consistent or specific as tachycardia in cases of hypoxia.

Choice D rationale:

Tachycardia, or an abnormally rapid heart rate, is a common physiological response to hypoxia. The body attempts to deliver more oxygen to tissues by increasing the heart rate. This compensatory mechanism helps maintain tissue perfusion in the face of reduced oxygen levels.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

Correct Answer is A

Explanation

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A patient has difficulty in breathing. The nurse provides oxygen therapy to the patient, after which the patient feels better. Which principle is involved in this situation?

A patient is given lorazepam, a benzodiazepine, to decrease symptoms of anxiety and restlessness on the evening prior to planned surgery. The nurse knows that the patient is experiencing a paradoxical drug reaction when which of the following is assessed?

A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.).

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

A nurse is assessing a patient who has chronic bronchitis. The nurse should expect the patient's chest to be which of the following shapes?

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to his client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?