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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

During inhalation, carbon dioxide levels are lower in the alveoli due to the exchange of gases. The higher concentration of carbon dioxide is found in the blood, which diffuses into the alveoli for elimination during exhalation.

Choice B rationale:

Alveoli do not collapse during the inhalation cycle. Surfactant, a substance produced by type II alveolar cells, reduces surface tension and prevents alveoli from collapsing, ensuring efficient gas exchange.

Choice C rationale:

Oxygen moves from the alveoli to the capillaries, while carbon dioxide moves from the capillaries to the alveoli. This exchange of gases occurs due to differences in partial pressures, facilitating the uptake of oxygen by red blood cells and the removal of carbon dioxide from the body.

Choice D rationale:

Exhaling carbon dioxide is a passive process that does not require significant effort. The respiratory muscles relax during exhalation, allowing the lungs to passively expel carbon dioxide from the body as a waste product of metabolism.

A. Provide non-slip footwear to patients during their stay. B. Keep the bed in high position to allow for ease of care. C. Institute a policy requiring a sitter for all patients above the age of 60. D. Avoid using a night light in the room to promote sleep.

Correct Answer is C

Explanation

Choice A rationale:

Providing non-slip footwear to patients during their stay is a good preventive measure, but it only addresses the risk of falls related to slippery floors. It does not address the overall fall risk, especially for elderly patients who may need constant supervision and assistance.

Choice B rationale:

Keeping the bed in a high position for ease of care might seem practical, but it increases the risk of falls when the patient attempts to get out of bed. Lowering the bed reduces the risk of injury if a fall occurs and is a more appropriate intervention.

Choice C rationale:

Instituting a policy requiring a sitter for all patients above the age of 60 is the best option among the choices provided. Elderly patients are at a higher risk of falls due to various factors such as weakened muscles, balance issues, and medication side effects. Having a dedicated sitter ensures constant supervision, timely assistance, and prompt intervention if the patient attempts to get out of bed, significantly reducing the risk of falls.

Choice D rationale:

Avoiding the use of a night light in the room to promote sleep is not a recommended intervention. While promoting sleep is essential for overall patient well-being, patient safety should always be the priority. Providing adequate lighting, especially at night, reduces the risk of falls and other accidents.

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The nurse is planning to obtain the pulse oximeter reading of a patient.
What action by the nurse is correct?