The nurse is planning to obtain the pulse oximeter reading of a patient.
What action by the nurse is correct?
Place the probe on a finger that has slow or delayed capillary refill.
Plan to document the pulse oximeter reading as a percent.
Assure the reading is taken in bright light, such as sunlight or fluorescent light.
Avoid removing dark nail polish before the reading is obtained.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Extension refers to the straightening of a joint and is the opposite of flexion. It is not the correct term for the described hand movement.
Choice B rationale:
Abduction is the movement of a body part away from the midline of the body. It does not describe the specific movement of the patient's hand toward the inner aspect of the forearm.
Choice C rationale:
Flexion is the bending of a joint, decreasing the angle between two body parts. When the nurse moves the patient's hand toward the inner aspect of the forearm, it is a flexion movement of the wrist.
Choice D rationale:
Adduction is the movement of a body part toward the midline of the body. It is not the correct term for the described hand movement.
Correct Answer is A
Explanation
Choice A rationale:
Moving the patient to the side of the bed is the first nursing action that should be implemented when assisting the patient to a lateral position for placement of a bedpan. This step ensures proper body mechanics and patient safety during the transfer. The nurse should assist the patient to the edge of the bed, farthest from them, and then help the patient turn onto their side, facing away from the nurse. This position facilitates the placement of the bedpan and maintains the patient's dignity and comfort.
Choice B rationale:
Placing the patient's arm over the chest is a subsequent step after moving the patient to the side of the bed. After the patient is in the lateral position, the nurse should assist in placing the uppermost arm comfortably over the chest to maintain balance and stability during the bedpan placement.
Choice C rationale:
Raising the bed to a proper working height is essential for the nurse's ergonomic safety and comfort during the procedure. However, it is not the first step in assisting the patient to a lateral position. The bed should be at a height that allows the nurse to work comfortably without straining their back, but this step comes after the patient has been safely positioned on their side.
Choice D rationale:
Turning the patient using the draw sheet is another appropriate technique for repositioning patients, especially when they are unable to assist with the movement. However, in this scenario, the nurse needs to assist the patient to a lateral position for the bedpan placement, which involves different techniques. Using a draw sheet might be necessary in other situations, such as when turning a bedridden patient in bed, but it is not the first action for placing a bedpan.
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