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 D
Explanation
Choice A reason: Dry skin is not a sign of respiratory alkalosis. Respiratory alkalosis is a condition where the blood pH is too high due to excessive loss of carbon dioxide through rapid breathing. Dry skin can be caused by dehydration, cold weather, or skin conditions.
Choice B reason: Diarrhea is not a sign of respiratory alkalosis. Diarrhea is a condition where the stool is loose and watery due to increased intestinal motility or infection. Diarrhea can cause metabolic acidosis, which is a condition where the blood pH is too low due to excessive loss of bicarbonate.
Choice C reason: Abdominal pain is not a sign of respiratory alkalosis. Abdominal pain is a symptom that can have many causes, such as gastritis, appendicitis, or irritable bowel syndrome. Abdominal pain can also cause hyperventilation due to anxiety or discomfort, but it is not a direct result of respiratory alkalosis.
Choice D reason: Hyperventilation is a sign of respiratory alkalosis. Hyperventilation is a condition where the breathing rate is faster than normal, causing excess carbon dioxide to be expelled from the lungs. This lowers the partial pressure of carbon dioxide in the blood, which increases the blood pH and causes alkalosis. Hyperventilation can be caused by anxiety, fever, pain, or lung diseases.
Correct Answer is A
Explanation
Choice A reason: A heart murmur is a common finding in clients who have mitral valve stenosis. It is a sound produced by turbulent blood flow through the narrowed valve. The murmur is usually heard as a low-pitched rumbling sound during diastole.
Choice B reason: Bradycardia is not a typical finding in clients who have mitral valve stenosis. Bradycardia is a slow heart rate, usually below 60 beats per minute. Mitral valve stenosis can cause tachycardia, which is a fast heart rate, due to increased cardiac workload and reduced cardiac output.
Choice C reason: Clubbing of the fingers is not a sign of mitral valve stenosis. Clubbing is a deformity of the fingertips and nails that occurs due to chronic hypoxia. Mitral valve stenosis can cause pulmonary hypertension and pulmonary edema, which can impair gas exchange, but not to the extent of causing clubbing.
Choice D reason: Barrel chest is not a sign of mitral valve stenosis. Barrel chest is a condition where the chest is enlarged and rounded due to chronic lung disease. Mitral valve stenosis can affect the lungs by increasing the pressure in the pulmonary circulation, but it does not cause structural changes in the chest wall.
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