Which nursing action should be implemented first when assisting the patient to a lateral position for placement of a bedpan?

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:

The nurse is not responsible since the nurse was following the doctor's orders. Rationale: While it is essential for nurses to follow physician orders, they also have a responsibility to assess the appropriateness and safety of those orders. If the nurse administers a medication that is clearly harmful or beyond the normal dosage, they have a duty to question the order and seek clarification from the physician. Administering a medication that is twice the normal dosage without questioning the order would be a breach of the nurse's responsibility.

Choice B rationale:

Only the nurse was responsible since the nurse administered the medication. Rationale: While the nurse did administer the medication, the ultimate responsibility lies with both the nurse and the physician. The nurse should have questioned the order if it appeared to be incorrect or unsafe. Nurses are advocates for their patients and have a duty to ensure the safety and well-being of those under their care.

Choice C rationale:

Both the nurse and the physician are responsible for the error. Rationale: This is the correct choice. Both the nurse and the physician share responsibility for the error. The nurse should have questioned the order, and the physician should have prescribed the correct dosage. Patient safety is a collaborative effort, and both healthcare providers are accountable for ensuring that the patient receives appropriate and safe care.

Choice D rationale:

Only the physician is responsible since he or she ordered the drug. Rationale: While the physician did order the drug, the nurse also has a responsibility to assess the order and question it if necessary. Nurses are trained to use their clinical judgment and critical thinking skills to ensure the safety of their patients. If the nurse administers a medication without questioning a clearly incorrect dosage, they share responsibility for the error.