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","F"]

Explanation

Choice A reason: Potassium concentration should be 10-20 mEq/100mL, not 1 mEq/10mL, to avoid irritation. Using an IV controller is correct, making this incorrect, as it’s an unsafe dilution compared to the nurse’s best practices for safe parenteral potassium administration.

Choice B reason: Checking IV access for blood return post-infusion ensures the potassium was delivered correctly, preventing extravasation. This aligns with IV therapy safety, making it a correct best practice the nurse should follow when administering parenteral potassium to the client.

Choice C reason: Pushing potassium as a bolus is dangerous, risking cardiac arrhythmias; it must be infused slowly. IV controller use is correct, making this incorrect, as it’s unsafe compared to the nurse’s best practices for administering potassium to a hypokalemic client.

Choice D reason: Hand veins are unsuitable for potassium, which is irritating and requires larger veins. Checking blood return is correct, making this incorrect, as it risks complications compared to the nurse’s best practices for safe potassium administration in the client.

Choice E reason: Keeping the client NPO is unnecessary for potassium administration, which addresses hypokalemia, not digestion. IV controller use is correct, making this incorrect, as it’s irrelevant to the nurse’s best practices for delivering parenteral potassium safely to the client.

Choice F reason: Using an IV controller ensures a safe, steady infusion rate for potassium, preventing cardiac complications. This aligns with medication safety protocols, making it a correct best practice the nurse should employ when administering parenteral potassium to the hypokalemic client.

A. Nonmaleficence. B. Fidelity. C. Beneficence. D. Veracity.

Correct Answer is D

Explanation

Choice A reason: Nonmaleficence ensures no harm but is less central than veracity, which ensures truthful disclosure for informed consent. Truthfulness enables autonomous decisions, making this incorrect, as it’s secondary to the ethical priority of honesty in the consent process for femur surgery.

Choice B reason: Fidelity involves keeping promises but doesn’t directly address the truthful disclosure required for informed consent. Veracity ensures the patient understands risks, making this incorrect, as it’s less relevant than honesty in the nurse’s role during the consent process for surgery.

Choice C reason: Beneficence promotes well-being but is secondary to veracity, which provides accurate information for the patient’s decision. Truthfulness is critical for consent, making this incorrect, as it’s not the primary ethical principle when soliciting informed consent for the femur procedure.

Choice D reason: Veracity, or truthfulness, is the most important ethical principle, ensuring the patient receives accurate information about risks and benefits for informed consent. This aligns with surgical ethical standards, making it the correct principle for the nurse to prioritize during the consent process.

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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

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L)? (Select all that apply)

Correct Answer is ["B","F"]

Explanation

The nurse is taking care of a 60-year-old client who is scheduled for open reduction internal fixation of the left femur. Which ethical principle is most important when soliciting informed consent from the patient?

Correct Answer is D

Explanation

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