A nurse is obtaining an oxygen saturation on a client.
Which of the following actions should the nurse take?
Relocate the sensor every 8 hrs.
Wait 10 sec after placing the probe before obtaining the oxygen saturation reading.
Choose a finger with a capillary refill less than 2 sec.
Place the sensor probe on the same extremity as an electronic blood pressure cuff.
The Correct Answer is C
Choice A rationale:
Relocating the sensor every 8 hours is not necessary when obtaining oxygen saturation readings unless there is a specific clinical reason to do so, such as skin irritation or poor perfusion at the sensor site. Frequent relocation can cause unnecessary disruption for the patient.
Choice B rationale:
Waiting 10 seconds after placing the probe before obtaining the oxygen saturation reading is not required. Modern pulse oximeters provide real-time readings, and there is no need to wait after placing the probe. The reading is usually stable within seconds.
Choice C rationale:
Choosing a finger with a capillary refill time of less than 2 seconds is an essential consideration when obtaining oxygen saturation readings. Capillary refill time is a measure of peripheral perfusion, and choosing a finger with good perfusion ensures accurate oxygen saturation measurements.
Choice D rationale:
Placing the sensor probe on the same extremity as an electronic blood pressure cuff is generally acceptable. However, it is crucial to ensure that the sensor does not interfere with the blood pressure cuff's function and that it is securely attached to the patient's finger for accurate readings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Following a subtotal thyroidectomy, the nurse should position the client in a way that minimizes strain on the surgical site and promotes respiratory function. The most appropriate position for this client is:
d) Semi-Fowler's.
Semi-Fowler's position, where the head of the bed is elevated at a 30 to 45-degree angle, helps reduce swelling at the surgical site and facilitates breathing. This position also minimizes tension on the suture line and aids in preventing strain on the neck.
The other options are not as suitable for post-thyroidectomy positioning:
a) Dorsal recumbent: This position involves lying on the back with the knees flexed. While it might be used in some situations, it doesn't specifically address the considerations after a thyroidectomy.
b) Supine: Lying flat on the back may not provide optimal support to the neck and could potentially increase discomfort.
c) Left lateral: Lying on the left side may not be as effective in reducing strain on the neck and surgical site compared to the semi-Fowler's position.
Correct Answer is D
Explanation
Choice A rationale:
Referring the client to a nutritionist is not the most appropriate action in this situation. While nutritionists can provide valuable information on infant feeding, the client's primary concern is the inability to afford baby formula. A case manager is better suited to address the client's financial and social needs.
Choice B rationale:
Referring the client to the primary care provider is not the most appropriate action in this situation. The primary care provider may not have the resources or expertise to address the client's financial and social concerns.
Choice C rationale:
Referring the client to a pediatric nurse practitioner is not the most appropriate action in this situation. While pediatric nurse practitioners can provide healthcare for infants, they may not have the resources to address the client's financial constraints.
Choice D rationale:
Referring the client to a case manager is the most appropriate action in this scenario. A case manager can assess the client's financial situation and connect them with appropriate resources, such as government assistance programs or local charities, to help cover the cost of baby formula. Case managers specialize in coordinating care and addressing social determinants of health.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.