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 C
Explanation
A. Speaking in short phrases can indicate increased effort or difficulty in breathing. While it suggests respiratory compromise, it is not an immediate concern unless it worsens or is accompanied by other severe symptoms.
B. Increased sputum production is common in clients with COPD and can indicate exacerbation or infection. It should be monitored closely but may not require immediate reporting unless it is severe or associated with other concerning symptoms.
C. This finding indicates increased respiratory effort and potential respiratory distress, which requires prompt attention and intervention.
D. A pulse oximetry reading of 90% indicates that the client's oxygen saturation is below the normal range but acceptable in client with COPD due to chronic hypoxemia.
Correct Answer is B
Explanation
A. This statement is incorrect because after instilling ointment, the client should close their eye gently and avoid blinking to allow the ointment to spread over the conjunctival sac.
B. When applying ophthalmic ointment, the client should pull down the lower eyelid to create a small pocket (conjunctival sac) and then apply a thin line of ointment along this pocket. This method helps the ointment distribute evenly over the affected area.
C. While this is a correct technique for cleaning around the eye, it is not directly related to the application of ophthalmic ointment.
D. This statement is unnecessary and may confuse the client. It's typically not required to use sterile gloves for applying ophthalmic ointment, and most ointments come with a sterile applicator or can be applied using clean hands if instructed to do so by a healthcare provider.
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