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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administer an analgesic 30 min before starting the procedure: Correct. Before performing wound irrigation, it is essential to provide pain relief to the client. Administering an analgesic 30 minutes before the procedure will help manage pain during wound irrigation.
B. Hold the syringe 5 cm (2 in) above the upper end of the wound: This action does not contribute to proper wound irrigation. The nurse should direct the irrigation solution to the wound site to cleanse it effectively.
C. Place the irrigation solution in a basin of cool water: Using cool water is not the best practice for wound irrigation. The irrigation solution should be at room temperature or a temperature specified by the healthcare provider.
D. Perform the wound irrigation with a 10mL syringe with an angiocatheter: Wound irrigation typically requires a larger volume of fluid to adequately cleanse the wound. A 10mL syringe may not be sufficient, and using an angiocatheter is not appropriate for wound irrigation. A larger syringe or irrigation solution bag with an appropriate wound irrigation tool is usually used.
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.
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