A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching?

Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds.

Use an adhesive oximetry probe for a client who has a latex allergy.

Remove polish from the client's fingernail before applying the oximetry probe.

Lubricate the tip of the oximetry probe.

Answer and Explanation

The Correct Answer is C

A.   Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds: Capillary refill time is not directly related to the placement of the pulse oximetry probe.
Capillary refill is assessed to evaluate peripheral perfusion.
B.   Use an adhesive oximetry probe for a client who has a latex allergy: The type of probe used for pulse oximetry is important, especially for clients with latex allergies. However, the correct action is to use a nonlatex probe or a probe that is compatible with the client's allergy, not necessarily an adhesive probe.
C.   Remove polish from the client's fingernail before applying the oximetry probe: Correct. Nail polish can interfere with the accuracy of pulse oximetry readings, as it may affect light transmission through the nail bed. It is essential to remove nail polish or artificial nails before applying the probe.
D.   Lubricate the tip of the oximetry probe: Lubricating the tip of the oximetry probe is not necessary for proper use and may interfere with the accuracy of readings.

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Correct Answer is C

Explanation

A. Obscure the client's name with a marker prior to disposal: While obscuring the client's name is better than not doing anything, it does not fully protect their confidential information. The paper could still be read by someone with access to it.
B. Place the paper in a trash can at the nurses' station: This action does not ensure the proper disposal of confidential information. It could be accessible to unauthorized individuals and breach the client's privacy.
C. Shred the paper in a secure container: Correct. Shredding confidential information is the best way to ensure that it cannot be accessed or read by unauthorized individuals.
D. Secure the paper in the nurse's personal locker: While securing the paper in a personal locker is better than leaving it exposed, it is not the most secure method of disposal for confidential
information.

A. "I will be sure to keep the crutch tips dry." B. "I will hold a crutch in each hand when sitting down." C. "I will place my weight on my underarms." D. "I will lead with my right leg when going upstairs."

Correct Answer is A

Explanation

A.Keeping the crutch tips dry is essential to prevent slipping and falling, which can lead to further injury. Moisture on the tips can reduce friction, making the crutches unstable on surfaces.

B.When sitting down, the correct technique involves holding both crutches in one hand and using the other hand to lower yourself safely into the chair. Holding a crutch in each hand can make it difficult to balance and sit down safely.

C.Placing weight on the underarms can cause nerve damage and pain. The correct technique is to place weight on the hands and use the muscles of the arms and shoulders to support the body.

D. When going upstairs with a fractured leg, the proper technique is to lead with the uninjured leg, not the injured one. This ensures stability and reduces the risk of further injury to the fractured leg.

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A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching?

Nursing Test Bank

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