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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Change the plan of care to provide different pain relief interventions:

While changing the plan of care may be necessary, it should be based on a thorough reassessment. Simply changing the plan without understanding the reasons for inadequate pain relief may not lead to effective outcomes.

B. Reassess the client to determine the reasons for inadequate pain relief.

Reassessment is a crucial step in the nursing process, especially when the desired outcomes are not achieved. By reassessing the client, the nurse can identify any factors contributing to the inadequate pain relief. This might include reevaluating the effectiveness of the current pain relief interventions, ensuring proper administration of medications, considering changes in the client's condition, or exploring any new factors affecting pain.

C. Teach the client about the plan of care for managing his pain:

Teaching is an important aspect, but in this case, reassessment takes precedence. Once the reasons for inadequate pain relief are determined, teaching can be tailored to address specific needs.

D. Wait to see whether the pain lessens during the next 24 hours:

If the pain is not adequately controlled, waiting for another 24 hours without action may prolong the client's discomfort and delay appropriate interventions. Reassessment and prompt adjustments to the plan of care are crucial for effective pain management.

A. Pallor B. Jaundice C. Cyanosis D. Erythema

Correct Answer is C

Explanation

A. Pallor:

Pallor refers to an unusually pale or white skin color. It is often associated with reduced blood flow, anemia, or shock. Pallor is characterized by a lack of the normal rosy color of the skin.

B. Jaundice:

Jaundice is a yellowing of the skin and mucous membranes due to an excess of bilirubin in the blood. It can be associated with liver dysfunction or other conditions affecting the normal breakdown and elimination of bilirubin.

C. Cyanosis:

Cyanosis is a bluish-gray discoloration of the skin and mucous membranes caused by a decrease in oxygen levels in the blood. It can result from various conditions affecting oxygenation, such as respiratory or circulatory problems. In the context of a broken leg, cyanosis on the affected leg could suggest compromised blood flow or oxygenation.

D. Erythema:

Erythema refers to redness of the skin, often due to increased blood flow to the area. It can be a normal response to irritation, injury, or inflammation. Unlike bluish-gray discoloration seen in cyanosis, erythema is characterized by a red appearance.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

Correct Answer is B

Explanation

A nurse performs an integumentary assessment of a client who has recently fallen and broken his leg. The nurse notes the skin coloring on the broken leg is bluish gray. What is the term for this change in skin color?

Correct Answer is C

Explanation

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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?