A nurse is preparing to measure a client's oxygen saturation and notes edema of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?
Toe
Skin fold
Earlobe
Finger
The Correct Answer is C
A. The toe could also be affected by the edema leading to inaccurate reading.
B. Placing the pulse oximeter probe on a skin fold is not recommended. Skin folds can obscure proper positioning of the probe and interfere with accurate readings. Additionally, skin folds may not adequately represent blood flow and oxygenation levels compared to other sites.
C. This location is recommended because it is usually free of the issues that can affect the extremities, such as poor circulation or changes in peripheral perfusion, and can provide a more reliable saturation reading.
D. The finger is the most common site for applying a pulse oximeter probe due to its accessibility and reliability. However, in cases where the fingers are not suitable, such as when there is significant edema or thickened toenails, alternative sites like the toe may be preferred.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This response may come across as judgmental or directive, which can be perceived as dismissive of the client's struggle. It does not acknowledge the complexity of the disorder or the client's feelings of helplessness, potentially hindering open communication and trust.
B. While this question encourages exploration of the underlying reasons for the behavior, it might feel probing or intrusive to the client. It could be interpreted as focusing solely on the behavior itself rather than acknowledging the client's recognition of its abnormality or their feelings of helplessness.
C. This response acknowledges and validates the client's awareness of the problem, which can be empowering. It reinforces the client's self-awareness and readiness to address their behavior, promoting a therapeutic alliance based on mutual understanding and respect.
D. This response demonstrates empathy and understanding of the client's feelings. It acknowledges the emotional struggle the client is experiencing and opens the door for further exploration of their feelings and thoughts. It encourages the client to express their emotions and concerns, which is essential in building a supportive therapeutic relationship.
Correct Answer is B
Explanation
A. Contact precautions primarily focus on preventing direct transmission of pathogens through physical contact. Therefore, wearing a mask is not typically required unless the client is also suspected or known to have respiratory infections that require airborne precautions. The standard precautions include wearing gloves and a gown when entering the client's room.
B. This is a key principle of contact precautions. The nurse should ensure that equipment (such as blood pressure cuffs, stethoscopes) and supplies (like thermometers) used for the client are dedicated solely to that client and are not shared with other clients. This helps prevent the spread of pathogens to other clients or areas of the healthcare facility.
C. Contact precautions involve limiting the client's movement outside of their room to essential purposes only. Allowing the client to leave the room frequently increases the risk of spreading infectious agents to other areas of the healthcare facility and to other individuals.
D. Potted plants can harbor soil that may contain microorganisms. Contact precautions focus on preventing direct transmission through physical contact, and while soil is not typically a medium for transmission of common healthcare-associated pathogens, removing plants helps maintain cleanliness and reduces potential reservoirs for contamination.
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