The nurse enters a client's room with a pulse oximetry machine and tells the client that the health care provider (HCP) has prescribed continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can alleviate the client's anxiety by providing which information about pulse oximetry?
It causes only mild discomfort at the site the probe is placed.
It requires insertion of only a small catheter in one nostril.
It is painless and safe.
It has an alarm to signal dangerous drops in oxygen levels.
The Correct Answer is C
A. It causes only mild discomfort at the site the probe is placed: Pulse oximetry is noninvasive and typically does not cause any discomfort unless the probe is left on too long or applied too tightly.
B. It requires insertion of only a small catheter in one nostril: This refers to oxygen delivery via nasal cannula, not pulse oximetry. Mentioning catheter insertion may increase the client’s apprehension, as it implies an invasive procedure, which pulse oximetry is not.
C. It is painless and safe: Pulse oximetry is a noninvasive method that uses light to measure oxygen saturation through a fingertip or earlobe, making it both painless and very safe for continuous monitoring.
D. It has an alarm to signal dangerous drops in oxygen levels: While accurate, focusing on alarms may heighten the client’s anxiety by implying that dangerous events are expected. This information is more relevant after the client is reassured about the procedure’s safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Have the client lean over an over-the-bed table:This position is sometimes used during posterior thoracic examination or for percussing lung fields, but it is not standard for routine chest auscultation. Most chest sounds can be assessed with the client sitting upright or lying down.
B. Use the bell of the stethoscope held lightly against the chest:The bell is best for detecting low-pitched sounds like some heart murmurs, not respiratory sounds. Lung sounds are higher-pitched and require use of the diaphragm for accurate auscultation.
C. Use the diaphragm of the stethoscope held firmly against the chest:This is the correct technique for auscultating lung sounds, which are typically high-pitched. Holding the diaphragm firmly ensures clear transmission of breath sounds such as crackles, wheezes, or rhonchi.
D. Instruct the client to take deep, rapid breaths through their nose:Deep breathing is appropriate during auscultation, but it should be done through the mouth. Breathing through the nose may reduce air entry and obscure abnormal sounds, making it harder to detect lung pathology.
Correct Answer is A
Explanation
A. Drive to breathe may be dependent on low levels of oxygen in the blood: Clients with emphysema may have chronically elevated CO₂ levels, which can blunt their central chemoreceptor response. As a result, their respiratory drive may rely more on peripheral chemoreceptors sensing low oxygen levels.
B. Respiratory rate may be increased a great part of the time: While some clients with emphysema may exhibit tachypnea during exertion or exacerbations, this is not a consistent or defining characteristic across all situations.
C. Lung stretch receptors may fail to monitor the patterns of breathing: Lung stretch receptors play a role in the Hering-Breuer reflex, but there is no evidence that they fail to function in emphysema. The issue in emphysema is gas trapping and reduced surface area for gas exchange, not receptor failure.
D. Intercostal muscles contract during inspiration, but fail to relax during expiration: The intercostal muscles assist with ventilation, particularly during increased respiratory effort. However, their relaxation in expiration is typically passive and not impaired in emphysema.
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