The nurse is caring for a client who is in the final stages of cancer, is depressed and distant.
The client asks the nurse, "Why is God punishing me?" Which would be the most appropriate action for the nurse to take?

Choice A rationale:

Placing the pulse oximeter probe on a finger with slow or delayed capillary refill can lead to inaccurate readings. Slow capillary refill indicates poor peripheral perfusion, which may affect the accuracy of pulse oximetry readings. The nurse should select a finger with normal capillary refill to obtain accurate readings.

Choice B rationale:

Documenting the pulse oximeter reading as a percent is the correct action. Pulse oximeter readings are expressed as percentages, representing the oxygen saturation level in the patient's blood. Normal oxygen saturation levels typically range from 95% to 100%. Documenting the reading in percent allows healthcare providers to monitor the patient's oxygenation status accurately.

Choice C rationale:

Assuring that the reading is taken in bright light, such as sunlight or fluorescent light, is incorrect. Bright light can interfere with the accuracy of pulse oximetry readings by causing the sensor to misinterpret external light as a pulsatile signal. To obtain accurate readings, the pulse oximeter should be used in a well-lit environment but away from direct bright light sources.

Choice D rationale:

Avoiding the removal of dark nail polish before obtaining the reading is incorrect. Dark nail polish can interfere with the pulse oximeter's ability to detect the pulsatile signal from the patient's finger, leading to inaccurate oxygen saturation readings. The nurse should advise the patient to remove dark nail polish or choose another finger without nail polish for the measurement.

Choice A rationale:

When a nurse delegates a specific intervention to unlicensed assistive personnel (UAP), the nurse transfers the responsibility for completing the task to the UAP. However, the nurse remains accountable for the outcome. Delegation does not absolve the nurse of their accountability; instead, it means that the nurse trusts the UAP to perform the task safely and effectively under their supervision. This approach allows healthcare teams to work collaboratively, improving efficiency and patient care outcomes.

Choice B rationale:

Nurses do have the authority to delegate interventions to UAP, but they must do so responsibly and within the scope of practice. Improper delegation or delegating tasks that UAP are not trained to perform can lead to adverse outcomes and legal consequences.

Choice C rationale:

While the UAP is responsible for their own actions, the nurse remains accountable for the overall patient care. Nurses must ensure that tasks are delegated to competent individuals and provide adequate supervision and guidance. The nurse cannot completely transfer all responsibility to the UAP without being accountable for the outcome.