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?

Capillary refill time is 2 seconds.

2+ edema of fingers and hands.

Radial pulse volume is 3+.

Blood pressure is 142/88 mm Hg.

Answer and Explanation

The Correct Answer is B

Choice B rationale

2+ edema of fingers and hands. Edema can interfere with the accuracy of pulse oximetry readings by affecting the perfusion of the area where the sensor is placed. This can lead to falsely low oxygen saturation readings.

Choice A rationale

Capillary refill time is 2 seconds. A capillary refill time of 2 seconds is within normal limits and is unlikely to affect the accuracy of the pulse oximetry reading.

Choice C rationale

Radial pulse volume is 3+. A strong radial pulse indicates good peripheral perfusion, which should not negatively impact the accuracy of the pulse oximetry reading.

Choice D rationale

Blood pressure is 142/88 mm Hg. While elevated blood pressure can have various effects on the body, it is not likely to directly affect the accuracy of a pulse oximetry reading.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

Administering pain medication as prescribed is the priority intervention for a client receiving hospice care with significant pain and discomfort. Effective pain management is essential to ensure the client’s comfort and quality of life. Pain relief is a primary goal in hospice care, and regular administration of pain medication helps manage symptoms and improve the client’s overall well-being.

Choice B rationale

Providing emotional support to the family is important in hospice care, as families often need assistance coping with the emotional challenges of caring for a loved one with a terminal illness. However, the priority intervention is to manage the client’s pain and discomfort effectively.

Choice C rationale

Assisting with daily activities is necessary for clients with limited mobility, but it is not the primary intervention. Ensuring the client’s comfort and pain relief takes precedence, as it directly impacts their quality of life.

Choice D rationale

Monitoring vital signs regularly is part of the overall care plan, but it is not the priority intervention. The focus should be on managing the client’s pain and discomfort to provide the best possible quality of life in hospice care.

A. Insert a rectal tube at specified intervals. B. Assist to a bedside commode 30 minutes after meals. C. Encourage the use of incontinence briefs. D. Administer a glycerin suppository 15 minutes after meals. E. Administer a glycerin suppository 15 minutes after meals.

Correct Answer is B

Explanation

Choice A rationale

Inserting a rectal tube at specified intervals is not a standard practice for bowel training regimens. This intervention is typically reserved for specific medical conditions and is not recommended for routine management of chronic fecal incontinence.

Choice B rationale

Assisting the client to a bedside commode 30 minutes after meals leverages the natural gastrocolic reflex, which stimulates bowel movements after eating. This intervention helps establish a regular bowel routine and is a key component of bowel retraining programs.

Choice C rationale

Encouraging the use of incontinence briefs does not address the underlying issue of bowel incontinence and may not help in establishing a regular bowel routine. This intervention is more focused on managing the symptoms rather than treating the condition.

Choice D rationale

Administering a glycerin suppository 15 minutes after meals can stimulate bowel movements, but it is not the first-line intervention for establishing a bowel training regimen. This approach may be used as an adjunct to other bowel retraining techniques.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Patient Data Exhibits Which intervention should the nurse prioritize for this client?

Correct Answer is A

Explanation

A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

Correct Answer is B

Explanation

The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?

The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

The nurse uses a sterile syringe to obtain a urine specimen from a client’s indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?