A client asks a nurse, “Why do I have to remove my nail polish in order for my pulse oximetry to be monitored?” Which is the best response by the nurse?

This is because the recovery position helps maintain the airway and prevent aspiration, and loosening the necktie prevents breathing restriction.

The other choices are wrong because:

Choice A is wrong because placing a stick or any object in the person’s mouth can cause injury to the teeth, gums, tongue or jaw and obstruct the airway. The person cannot swallow or bite their tongue during a seizure.

Choice B is wrong because recording the time of the seizure is not the first priority. The first priority is to ensure the safety and comfort of the person.

Choice C is wrong because restraining the limbs can cause injury or fracture, increase agitation and prolong the seizure. The nurse should protect the person from injury by moving furniture away and padding the head.

Normal ranges for seizure duration are usually less than 5 minutes for generalized tonic-clonic seizures and less than 15 seconds for absence seizures. If the seizure lasts longer than 5 minutes, or if the person has repeated seizures without regaining consciousness, it is considered a medical emergency and requires immediate treatment.

This is because coughing can indicate aspiration of the feeding into the lungs, which can lead to pneumonia and other serious complications. Aspiration is reported in up to 89% of patients receiving nasogastric tube feeding.

Therefore, the nurse should prioritize assessing the client for signs of aspiration and ensuring proper tube placement.

Choice B is wrong because mild abdominal cramps are a common side effect of nasogastric tube feeding and do not require immediate intervention unless they are severe or persistent.

Choice C is wrong because high-pitched bowel sounds are normal and indicate peristalsis and digestion.

They do not indicate a problem with the tube feeding.

Choice D is wrong because one to two soft bowel movements per day are desirable and indicate adequate nutrition and hydration.

They do not indicate a problem with the tube feeding.

Normal ranges for gastric residual volume are less than 200 mL for adults and less than 100 mL for children. Normal ranges for pH of gastric aspirate are 1 to 5.