The nurse cares for a client diagnosed with Type 1 diabetes and Raynaud’s disease. The orders include continuous pulse oximetry monitoring. Which situation requires an intervention by the nurse?

The nurse discusses the pulse oximetry findings with the client.

The client has the pulse oximeter and automatic blood pressure cuff on the same arm.

The pulse oximeter is placed on the ring finger of the client’s right hand.

The nurse instructs nursing assistive personnel to obtain a pulse oximetry reading.

Answer and Explanation

The Correct Answer is B

Choice A reason: Discussing pulse oximetry findings with the client is appropriate and promotes understanding, not requiring intervention. A blood pressure cuff on the same arm affects readings, making this incorrect, as it’s a correct nursing action for the client with Raynaud’s and diabetes.

Choice B reason: A blood pressure cuff on the same arm as the pulse oximeter disrupts blood flow, causing inaccurate readings, especially in Raynaud’s disease. This requires intervention, aligning with monitoring accuracy standards, making it the correct situation for the nurse to address immediately.

Choice C reason: Placing the pulse oximeter on the ring finger is appropriate, avoiding Raynaud’s-affected areas. A cuff on the same arm is problematic, making this incorrect, as it’s a standard placement not requiring intervention in the client’s monitoring setup.

Choice D reason: Instructing assistive personnel to obtain readings is acceptable if within their scope. A cuff on the same arm affects accuracy, making this incorrect, as it’s not an issue compared to the intervention needed for the pulse oximeter placement error.

Choice E reason: An LPN recording the pulse from the oximeter is within their role and not problematic. A cuff on the same arm requires intervention, making this incorrect, as it’s a correct action unlike the inaccurate monitoring setup needing nurse correction.

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Correct Answer is B

Explanation

Choice A reason: Assessing pain at the insertion site is important but less urgent than ensuring vascular patency post-catheterization. Checking pulses detects complications like occlusion, making this incorrect, as it’s secondary to the nurse’s priority of monitoring for vascular issues immediately post-procedure.

Choice B reason: Assessing dorsalis pedis and posterior tibial pulses is most important to detect vascular complications, such as arterial occlusion, post-cardiac catheterization. This aligns with post-procedure protocols, making it the correct action to ensure limb perfusion and prevent serious complications immediately.

Choice C reason: Observing the access site for bleeding is key but secondary to ensuring distal perfusion via pulses. Vascular occlusion is a greater risk, making this incorrect, as it’s less urgent than the nurse’s priority of checking pulses post-cardiac catheterization.

Choice D reason: Checking capillary refill time assesses perfusion but is less specific than pulse assessment for detecting arterial issues post-catheterization. Pulses are the priority, making this incorrect, as it’s secondary to the nurse’s focus on immediate vascular integrity post-procedure.

A. “I have had unprotected sex with multiple partners.” B. “I ate shellfish about 2 weeks ago at a local restaurant.” C. “I was an intravenous drug abuser in the past and shared needles.” D. “I had a blood transfusion 30 years ago after major abdominal surgery.”

Correct Answer is B

Explanation

Choice A reason: Unprotected sex is a risk for hepatitis B or C, not A, which is fecal-oral. Shellfish consumption is a common source, making this incorrect, as it doesn’t support the nurse’s diagnosis of hepatitis A based on the client’s history.

Choice B reason: Eating contaminated shellfish is a common cause of hepatitis A, transmitted via the fecal-oral route, with symptoms appearing 2-6 weeks later. This aligns with the diagnosis, making it the correct statement supporting the client’s hepatitis A diagnosis.

Choice C reason: Sharing needles spreads hepatitis B or C, not A, which is foodborne. Shellfish is a hepatitis A source, making this incorrect, as it’s unrelated to the nurse’s evaluation of the client’s flu-like symptoms and jaundice.

Choice D reason: Blood transfusions before 1992 risked hepatitis C, not A, which is fecal-oral. Eating shellfish supports hepatitis A, making this incorrect, as it doesn’t align with the nurse’s diagnosis based on the client’s jaundice and flu-like symptoms.

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The nurse cares for a client diagnosed with Type 1 diabetes and Raynaud’s disease. The orders include continuous pulse oximetry monitoring. Which situation requires an intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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