The newly admitted patient has contractures of both lower extremities.
What nursing intervention should be included in this patient's plan of care?

Choice A rationale:

Placing the pulse oximeter probe on a finger with slow or delayed capillary refill can lead to inaccurate readings. Slow capillary refill indicates poor peripheral perfusion, which may affect the accuracy of pulse oximetry readings. The nurse should select a finger with normal capillary refill to obtain accurate readings.

Choice B rationale:

Documenting the pulse oximeter reading as a percent is the correct action. Pulse oximeter readings are expressed as percentages, representing the oxygen saturation level in the patient's blood. Normal oxygen saturation levels typically range from 95% to 100%. Documenting the reading in percent allows healthcare providers to monitor the patient's oxygenation status accurately.

Choice C rationale:

Assuring that the reading is taken in bright light, such as sunlight or fluorescent light, is incorrect. Bright light can interfere with the accuracy of pulse oximetry readings by causing the sensor to misinterpret external light as a pulsatile signal. To obtain accurate readings, the pulse oximeter should be used in a well-lit environment but away from direct bright light sources.

Choice D rationale:

Avoiding the removal of dark nail polish before obtaining the reading is incorrect. Dark nail polish can interfere with the pulse oximeter's ability to detect the pulsatile signal from the patient's finger, leading to inaccurate oxygen saturation readings. The nurse should advise the patient to remove dark nail polish or choose another finger without nail polish for the measurement.

Choice A rationale:

Making sure the consent is signed and in the patient's chart in a timely manner is an important step in the consent process. However, the most appropriate action for the nurse in this situation is to verify the necessity of the surgical procedure before placing the consent in the chart. This is crucial to ensure that the patient fully understands the procedure they are consenting to and that it is medically necessary. Verifying the necessity of the surgical procedure helps in preventing unnecessary procedures, promoting patient safety, and adhering to ethical principles.

Choice B rationale:

Verifying the necessity of the surgical procedure before placing the consent in the chart is the most appropriate action for the newly licensed nurse. This step ensures that the procedure is medically necessary, aligns with the patient's condition, and promotes informed decision-making. By confirming the necessity, the nurse upholds the principle of beneficence, ensuring the patient's well-being, and autonomy, allowing the patient to make informed decisions about their healthcare.

Choice C rationale:

Asking a family member to translate the consent into the language the patient understands might be helpful in improving the patient's understanding of the procedure. However, the primary concern in this situation is verifying the necessity of the surgical procedure. While communication is essential, it does not address the core issue of confirming the medical need for the surgery.

Choice D rationale:

Explaining the risks and benefits of the surgical procedure prior to getting a signature is a vital step in the consent process. However, the question specifically asks for the most appropriate action, which is to verify the necessity of the procedure. Explaining the risks and benefits is an important follow-up step after ensuring the procedure's necessity.