On arrival at the intensive care unit, a critically ill patient suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the patient’s arterial oxygen saturation (SaO₂) noninvasively. Which vital sign abnormality may alter pulse oximetry values?

Tachycardia

Hypotension

Tachypnea

Fever

Answer and Explanation

The Correct Answer is B

Choice A: Tachycardia

Tachycardia, defined as a heart rate exceeding 100 beats per minute, can affect the accuracy of pulse oximetry readings. When the heart beats too quickly, it may not fill with enough blood between beats, leading to reduced perfusion and oxygen delivery to tissues. However, while tachycardia can influence the readings, it is not the most significant factor compared to hypotension.

Choice B: Hypotension

Hypotension, or low blood pressure, significantly impacts pulse oximetry accuracy. When blood pressure is low, there is reduced perfusion to peripheral tissues, including the extremities where pulse oximeters are typically placed. This reduced perfusion can lead to inaccurate readings, as the device may not detect sufficient blood flow to measure oxygen saturation accurately. Hypotension is a critical factor that can alter pulse oximetry values, making it the most relevant choice.

Choice C: Tachypnea

Tachypnea, or rapid breathing, can affect oxygen levels in the blood but does not directly interfere with the pulse oximeter’s ability to measure oxygen saturation. While it indicates respiratory distress and can lead to hypoxemia, the pulse oximeter can still provide accurate readings unless accompanied by other factors like low perfusion.

Choice D: Fever

Fever can cause peripheral vasodilation, which might theoretically affect pulse oximetry readings by altering blood flow to the extremities. However, this effect is generally minimal compared to the impact of hypotension. Fever alone is unlikely to cause significant inaccuracies in pulse oximetry measurements.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

Choice A: Instruct the patient to withhold any medication for diuretic therapy.

Reason: Diuretics can lead to dehydration and electrolyte imbalances, which can complicate the cardiac catheterization procedure. Withholding diuretics helps to maintain fluid balance and reduce the risk of complications during the procedure

Choice B: Prepare to administer fluids 2 hours before the procedure for patients with renal dysfunction.

Reason: Administering fluids before the procedure helps to prevent contrast-induced nephropathy, especially in patients with renal dysfunction. Hydration helps to flush out the contrast material used during the procedure, reducing the risk of kidney damage.

Choice C: Advise the patient to take all anticoagulants.

Reason: This choice is incorrect. Patients are usually advised to withhold anticoagulants before a cardiac catheterization to reduce the risk of bleeding complications. The decision to continue or withhold anticoagulants should be based on a careful assessment of the patient’s risk of thromboembolism versus the risk of bleeding.

Choice D: Administer steroids if the patient has an allergy to iodine-based contrast.

Reason: Administering steroids is a common premedication strategy for patients with a known allergy to iodine-based contrast media. Steroids help to reduce the risk of an allergic reaction during the procedure.

Choice E: Ensure that the patient is NPO for a minimum of 2 hours before the procedure.

Reason: Ensuring that the patient is NPO (nothing by mouth) helps to reduce the risk of aspiration during the procedure. Typically, patients are advised to be NPO for 6-8 hours before the procedure, but a minimum of 2 hours is essential.

A. Client who displays plantar flexion when the bottom of the foot is stroked. B. Client who consistently demonstrates decortication when stimulated. C. Client whose Glasgow Coma Scale (GCS) has changed from 15 to 12. D. Client whose deep tendon reflexes have become hyperactive.

Correct Answer is C

Explanation

Choice A Reason:

The client who displays plantar flexion when the bottom of the foot is stroked is exhibiting a normal reflex response known as the plantar reflex. This response indicates that the corticospinal tract is functioning properly. In adults, the normal response is plantar flexion of the toes, which means the toes curl downward. This is not an immediate cause for concern and does not indicate a life-threatening condition.

Choice B Reason:

The client who consistently demonstrates decortication when stimulated is showing signs of severe brain injury. Decorticate posturing is characterized by the arms being flexed at the elbows and held tightly to the chest, with the legs extended and feet turned inward. This type of posturing indicates damage to the cerebral hemispheres, thalamus, or midbrain. While this is a serious condition, it is not necessarily the most immediate priority compared to a sudden change in the Glasgow Coma Scale.

Choice C Reason:

The client whose Glasgow Coma Scale (GCS) has changed from 15 to 12 is the nurse’s first priority. The GCS is a critical tool used to assess a patient’s level of consciousness, with scores ranging from 3 (deep coma) to 15 (fully awake and alert). A drop in GCS score indicates a significant decline in neurological function, which could be due to increased intracranial pressure, bleeding, or other acute changes in the brain. This requires immediate assessment and intervention to prevent further deterioration.

Choice D Reason:

The client whose deep tendon reflexes have become hyperactive is showing signs of hyperreflexia. Hyperactive reflexes can indicate an upper motor neuron lesion, which affects the descending corticospinal tract. While this is a concerning sign that warrants further investigation, it is not as immediately critical as a sudden change in the GCS score.

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Naxlex Comprehensive Predictor Exams

In addition to assessing peripheral pulses and auscultating the patient’s heart and lung sounds, which action will be implemented by the nurse before a cardiac catheterization? Select all that apply. One, some, or all responses may be correct.

Correct Answer is ["A","B","D","E"]

Explanation

The nurse has just received a report on a group of clients on the neurosurgical unit. Which client is the nurse’s first priority?

Correct Answer is C

Explanation

The nurse is assessing a patient with gastroesophageal reflux disease (GERD). Which finding would the nurse expect to observe? Select all that apply. One, some, or all responses may be correct.

Which sign or symptom would the nurse anticipate in a patient diagnosed with tuberculosis? Select all that apply. One, some, or all responses may be correct.

The nurse is taking care of a 60-year-old client with constant bubbling in the water seal chamber. The nurse knows that constant bubbling in the water seal of a chest drainage system indicates which problem?

A postoperative client following a thyroidectomy suddenly develops difficulty breathing, stridor, and an increase in swelling of the anterior neck area. What should the nurse do first?

The nurse administers amiodarone to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? (Select all that apply)

A client who had a bronchoscopy 2 hours ago asks for a drink of water. What action would the nurse take initially to assure client safety?

A nurse is caring for a client who has Addison’s disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take?

A male client was admitted with a left-sided stroke this morning. The assistive personnel asks about meeting the client’s nutritional needs. Which response by the nurse is appropriate?