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 D

Explanation

A. Confidentiality: Confidentiality refers to the duty to respect and protect the client's private information and not disclose it without the client's consent or appropriate legal authorization.

B. Nonmaleficence: Nonmaleficence means "do no harm." It is the ethical principle that requires healthcare professionals to avoid causing harm to their clients and to balance potential benefits with possible risks.

C. Accountability: Accountability is the ethical principle that refers to the responsibility of healthcare professionals to answer for their actions and decisions in providing care to clients.

D. Autonomy: Correct. Autonomy is the ethical principle that respects a person's right to make their own decisions and about their healthcare. Allowing a client to make decisions about their treatment plan is an example of promoting autonomy and respecting their right to
selfdetermination.

A. Remove dentures. B. Apply a shroud around the body with a visible identification tag. C. Clean soiled areas of the body. D. Place the client's head in a dependent position.

Correct Answer is C

Explanation

A. Remove dentures:

Removing dentures is a step often performed during post-mortem care but may not necessarily need to be completed before family viewing, especially if the dentures are normally worn by the deceased.

B. Apply a shroud around the body with a visible identification tag:

Applying a shroud with a visible identification tag is an important step for dignified covering and identification but might be more appropriate after the family has viewed the body.

C. Clean soiled areas of the body:

This is the most appropriate action to ensure the body appears as dignified and comfortable as possible for family viewing. It involves cleaning any visible soiled areas to provide a respectful presentation to the family.

D. Place the client's head in a dependent position:

Placing the client's head in a dependent position is not typically necessary or recommended in this context. The goal is to ensure the body appears as natural and dignified as possible.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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