A nurse is reinforcing discharge teaching with the parents of an infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?
The pulse oximeter might not be accurate during times of excessive movement.
We will notify the doctor if the pulse oximeter consistently reads 100%.
The probe of the pulse oximeter can be applied to a finger or a toe.
We will rotate the probe of the pulse oximeter every 24 hours.
The Correct Answer is B
Choice A reason: The pulse oximeter might not be accurate during times of excessive movement is a correct statement, as movement can interfere with the detection of the pulse and the oxygen saturation. The parents should try to keep the infant still and calm while using the pulse oximeter.
Choice B reason: We will notify the doctor if the pulse oximeter consistently reads 100% is an incorrect statement, as it indicates a misunderstanding of the normal range of oxygen saturation. The parents should not be alarmed if the pulse oximeter reads 100%, as it means that the infant's blood is fully saturated with oxygen. The normal range of oxygen saturation for infants is 95% to 100%.
Choice C reason: The probe of the pulse oximeter can be applied to a finger or a toe is a correct statement, as these are suitable sites for measuring the oxygen saturation in infants. The parents should make sure that the probe fits snugly and securely on the infant's finger or toe.
Choice D reason: We will rotate the probe of the pulse oximeter every 24 hours is a correct statement, as it helps to prevent skin irritation, pressure ulcers, or infection from prolonged contact with the probe. The parents should also check the infant's skin regularly for any signs of redness, swelling, or pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Collecting urine from the catheter's port is not a correct action for the nurse to take, as it can introduce contamination and infection into the urinary tract. The nurse should insert a new, sterile catheter into the bladder and collect the urine directly from the catheter.
Choice B reason: Using a sterile specimen container is a correct action for the nurse to take, as it ensures that the urine sample is not contaminated by any bacteria or other substances. The nurse should label the container with the client's name, date, and time of collection and send it to the laboratory as soon as possible.
Choice C reason: Using sterile water to inflate the balloon is not a relevant action for the nurse to take, as it applies to an indwelling catheter, not a straight catheter. A straight catheter does not have a balloon and is removed after the urine is drained.
Choice D reason: Instructing the client to clean from front to back with an antiseptic solution is a good action for the nurse to take, as it helps to prevent the introduction of bacteria from the anal area into the urethra. However, it is not the best answer, as it is a general hygiene measure, not a specific action for obtaining a urine specimen.
Correct Answer is D
Explanation
Choice A reason: Prone is not the best position to allow maximal lung expansion. Prone is a position where the client lies on their stomach, with their head turned to one side. Prone can help to improve oxygenation in some cases of acute respiratory distress syndrome (ARDS), but it can also increase the risk of pressure ulcers, facial edema, and airway obstruction.
Choice B reason: Side-lying is not the best position to allow maximal lung expansion. Side-lying is a position where the client lies on their side, with their head supported by a pillow. Side-lying can help to prevent aspiration and reduce the work of breathing in some clients, but it can also compromise the ventilation of the dependent lung.
Choice C reason: Supine is not the best position to allow maximal lung expansion. Supine is a position where the client lies on their back, with their head and shoulders slightly elevated. Supine can help to maintain a patent airway and facilitate suctioning in some clients, but it can also increase the risk of atelectasis, pneumonia, and hypoxemia.
Choice D reason: Upright is the best position to allow maximal lung expansion. Upright is a position where the client sits or stands with their back straight and their chest expanded. Upright can help to improve lung compliance, reduce airway resistance, and enhance gas exchange in clients with respiratory failure. Upright can also reduce the pressure on the diaphragm and abdominal organs, and promote the drainage of secretions.
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