A nurse is preparing to obtain the oxygen saturation of a client who has peripheral edema and thickened toenails. Which of the following actions should the nurse take?
Attach a probe carefully to the client's finger to prevent discomfort.
Apply a sensor pad to the client's forehead.
Secure a probe to one of the client's toes.
Obtain a pulse oximetry reading when peripheral edema has decreased.
The Correct Answer is B
A. Attach a probe carefully to the client's finger to prevent discomfort. Peripheral edema may impair circulation, leading to inaccurate readings.
B. Apply a sensor pad to the client's forehead. The forehead provides a more accurate reading when peripheral circulation is compromised.
C. Secure a probe to one of the client's toes. Thickened toenails and edema may interfere with an accurate reading.
D. Obtain a pulse oximetry reading when peripheral edema has decreased. The nurse should not delay obtaining an oxygen saturation reading if an alternative site is available.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Mix the medications together and administer through the NG tube. Incorrect because medications should be given separately to prevent drug interactions and ensure each is fully delivered.
B. Crush the sublingual medication into powder form. Incorrect because sublingual medications are designed to be absorbed through the oral mucosa, not the gastrointestinal tract. Crushing them negates their intended action.
C. Dissolve crushed tablet medications in sterile water. Sterile water is preferred for dissolving medications because it reduces the risk of bacterial contamination and prevents potential drug interactions that may occur with other fluids.
D. Flush the tube with 5 mL saline between each medication. Incorrect because a minimum of 15-30 mL of water is recommended between medications to prevent tube blockage.
Correct Answer is B
Explanation
A. "I need to have an attorney sign my advance directives." An attorney is not required to sign an advance directive. The document typically requires the client’s signature and witnesses but does not need legal counsel unless state laws specify otherwise.
B. "I have a living will that outlines my wishes if I am unable to make decisions." A living will is a type of advance directive that specifies the client’s preferences for medical care if they become unable to make decisions. This statement shows understanding.
C. "I must have a family member appointed to make my health care decisions." While a client can appoint a family member as a healthcare proxy, it is not required. The client may choose any trusted individual to act as their healthcare power of attorney.
D. "I will need to sign a document stating that I want to be resuscitated if I require CPR." A Do Not Resuscitate (DNR) order is signed when a client chooses not to receive CPR. If the client wants resuscitation, no additional documentation is required—healthcare providers automatically provide life-saving measures unless a DNR order is in place.
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