During vital sign assessment of a client, the practical nurse (PN) counts the left radial pulse at 88 beats/minute, and the pulse oximeter clipped to a finger on the left hand records a pulse rate of 68 beats/minute with an oxygen saturation of 95%. Which of the following should the PN do first?
Notify the charge nurse.
Reposition the oximeter clip.
Document the conflicting data.
Measure the blood pressure.
The Correct Answer is B
A. Notify the charge nurse: Notifying the charge nurse would be appropriate if the discrepancy persists after troubleshooting. However, first steps should involve checking the equipment to rule out technical errors before escalating the concern.
B. Reposition the oximeter clip: A discrepancy between the manual pulse and the pulse oximeter reading often indicates a technical issue, such as poor sensor placement or poor perfusion. Repositioning the oximeter clip ensures accurate data collection before proceeding with further interventions.
C. Document the conflicting data: Documentation is important, but before recording inconsistent or potentially inaccurate findings, the nurse should first validate the data by ensuring correct technique and equipment function.
D. Measure the blood pressure: Measuring blood pressure is part of a full vital signs assessment but does not address the immediate concern of conflicting pulse readings. Equipment issues must be corrected first to ensure all vital signs are accurate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Sacrum: The sacrum is a common site for pressure ulcers in a supine position, but once the client is turned onto the side, pressure shifts away from the sacrum to lateral body surfaces. It is not the most at-risk area in the new position.
B. Ischial tuberosities: The ischial tuberosities bear weight when sitting, not typically when lying in a lateral position. Therefore, they are less likely to be the first site to show erythema when turned onto the side.
C. Lateral malleolus: The lateral malleolus can be at risk when the lower legs rub against the bed, but it is a smaller surface area and would show signs later compared to larger, more pressure-exposed areas like the iliac crest.
D. Iliac crest: The iliac crest on the side the client is turned onto bears significant pressure in the lateral position. It is a major bony prominence directly exposed to force against the mattress, making it the most likely site to show early erythema.
Correct Answer is A
Explanation
A. Remind the UAP of the need to turn the client every 2 hours to prevent skin breakdown: Frequent repositioning is critical to prevent pressure injuries in bedfast clients. Although the redness blanched (indicating no permanent damage yet), regular turning is necessary to maintain skin integrity and prevent future breakdown.
B. Confirm that turning this client once a shift is sufficient since no skin damage occurred: Turning once per shift is inadequate for pressure injury prevention. Clients at risk need to be repositioned at least every two hours to minimize sustained pressure on bony prominences.
C. Instruct the UAP to cleanse the area thoroughly to remove any remaining skin debris: Since there is no open wound, aggressive cleansing is unnecessary and could actually irritate the skin further. The focus should be on pressure relief rather than harsh skin cleansing.
D. Gather supplies to apply a sterile dressing over the site to reduce risk for infection: A sterile dressing is not appropriate for blanchable redness without skin breakdown. Preventive measures like repositioning and pressure relief are the correct interventions at this stage.
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