A nurse is preparing to measure a client’s level of oxygen saturation on a patient who has had a bilateral lower leg amputation. He noticed the patient’s hands are very edematous.
The nurse should apply the pulse oximeter probe to which of the following locations?
Skin fold
Toe
Earlobe
Finger
The Correct Answer is C
A. Skin fold:
This may not be the best choice in this situation because the skin fold might not provide an accurate reading, especially if the hands are edematous.
B. Toe:
While the toe is a common site for pulse oximetry, in a patient with bilateral lower leg amputations, it might not be the most practical option. The nurse might face challenges in securing the pulse oximeter probe on the toe, and the accuracy of the reading could be affected.
C. Earlobe:
This is often a suitable alternative site for pulse oximetry when peripheral perfusion is compromised in the extremities. In this case, with bilateral lower leg amputations and edematous hands, applying the pulse oximeter probe to the earlobe is a good choice.
D. Finger:
In a patient with edematous hands, the finger might not be the best choice as the edema could affect the accuracy of the measurement. Additionally, if the patient has lower leg amputations, using the earlobe or another alternative site may be more appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Comatose:
Coma refers to a state of deep unconsciousness where the individual is unresponsive to stimuli, including pain or external stimulation. In the scenario described, the patient is not comatose because they can be awakened by gentle shaking and calling their name.
B. Awake and alert:
This term describes a state of full alertness and responsiveness to the environment. The patient in the scenario is not fully awake and alert since they appear drowsy most of the time and require external stimuli to be awakened.
C. Lethargic:
Lethargy is characterized by drowsiness, reduced alertness, and a sluggish response to stimuli. In the scenario, the patient is described as drowsy most of the time but can be awakened by gentle shaking and calling their name. This aligns with the characteristics of lethargy.
D. Stuporous:
Stupor is a state of reduced responsiveness where the individual can be aroused only by vigorous or painful stimuli. The patient in the scenario does not fit the criteria for stupor as they can be awakened by gentle shaking and calling their name.
Correct Answer is B
Explanation
A. Round and Taut:
A round and taut abdomen may be normal, depending on the individual's body habitus and muscle tone. It might indicate normal abdominal distension associated with gas or a meal.
B. White Striae (Stretch Marks)
White striae, commonly known as stretch marks, on the abdomen may warrant further investigation. While they are often benign and associated with conditions like weight gain or pregnancy, they can sometimes be indicative of underlying issues such as Cushing's syndrome or other factors. Further inquiry or investigation into the client's medical history may be needed to understand the cause of the white striae.
C. Symmetrical, Rounded Shape:
A symmetrical and rounded abdominal shape is generally considered a normal finding. It suggests that the abdominal muscles are intact and that there is no obvious asymmetry or abnormal protrusion.
D. Soft and Non-Tender:
A soft and non-tender abdomen is a normal finding. It suggests that the abdominal
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