The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Blood pressure is 142/88 mm Hg.

Radial pulse volume is 3+.

2+ edema of fingers and hands.

Capillary refill time is 2 seconds.

Answer and Explanation

The Correct Answer is C

A. Blood pressure is 142/88 mm Hg:

While elevated blood pressure may have implications for cardiovascular health, it is not directly related to oxygen saturation levels measured by a pulse oximeter.

B. Radial pulse volume is 3+:

A strong radial pulse volume suggests adequate peripheral perfusion, which would not typically contribute to a low oxygen saturation reading.

C. 2+ edema of fingers and hands:

Edema of the fingers and hands can impair the transmission of light through tissues, which may interfere with the accuracy of oxygen saturation readings obtained from a pulse oximeter. Edematous tissues may absorb light and lead to falsely low readings.

D. Capillary refill time is 2 seconds:

Normal capillary refill time indicates adequate peripheral circulation, which would not typically contribute to a low oxygen saturation reading.

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Correct Answer is C

Explanation

A. Risk for infection:

Neuropathy can compromise the ability to detect injuries or wounds on the feet. Consequently, there's a risk of wounds going unnoticed, becoming infected, and leading to serious complications. While preventing infection is important, the primary concern in this scenario is preventing the occurrence of wounds or skin breakdown in the first place.

B. Impaired physical mobility:

Impaired physical mobility may be a concern for clients with neuropathy, especially if it affects their ability to walk or perform activities of daily living. However, in this scenario, the client is reporting increasing numbness and tingling in the lower extremities, indicating a sensory issue rather than a motor one. Therefore, while physical mobility is important, it may not be the immediate priority for promoting foot care in this case.

C. Risk for impaired skin integrity:

This option addresses the potential risk of skin breakdown or damage due to decreased sensation in the lower extremities, which is characteristic of neuropathy. With increasing numbness and tingling, there's a higher risk that the client may not be able to perceive injuries or pressure points, leading to skin damage or ulceration. Preventing skin integrity issues is crucial to avoid complications such as infections or wounds.

D. Self-care deficit:

Neuropathy can indeed impact a person's ability to perform self-care activities, including foot care. However, the priority in this scenario is to prevent complications related to neuropathy, such as skin integrity issues, rather than addressing deficits in self-care abilities. While self-care education and support may be necessary in the long term, immediate intervention to prevent skin breakdown takes precedence.

A. Washes hands before handling the needle and syringe. B. Wears gloves to dispose of the needle and syringe. C. Dons a face mask before administering the medication. D. Removes needle before discarding used syringes.

Correct Answer is A

Explanation

A. Washes hands before handling the needle and syringe:

This action demonstrates an understanding of standard precautions. Hand hygiene, including washing hands before and after handling needles and syringes, is a fundamental component of standard precautions.

B. Wears gloves to dispose of the needle and syringe:

While wearing gloves is important for protecting oneself from potential exposure to bloodborne pathogens, it is part of personal protective equipment (PPE) precautions rather than standard precautions. Standard precautions primarily focus on hand hygiene and barrier precautions such as gloves, gowns, and masks when appropriate.

C. Dons a face mask before administering the medication:

Wearing a face mask is not typically necessary for routine administration of medications, unless there is a risk of splashes or sprays of blood or body fluids. While it's important to protect mucous membranes from exposure to potentially infectious materials, the routine use of a face mask for medication administration is not a component of standard precautions.

D. Removes needle before discarding used syringes:

This action is unsafe and does not demonstrate an understanding of standard precautions. Removing the needle before discarding the syringe increases the risk of needlestick injuries. Proper needle disposal involves keeping the needle intact with the syringe and disposing of them together in a puncture-resistant container.

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The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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