A Cardiovascular nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?
Toe.
Earlobe.
Skin fold.
Finger.
The Correct Answer is B
Choice A rationale:
Applying the pulse oximeter probe to the toe is not the most appropriate location. While toe measurements can be used, the fingers are more commonly used due to their accessibility and accuracy. Edema in the hands could affect the accuracy of readings.
Choice B rationale:
The nurse should apply the pulse oximeter probe to the earlobe. This choice is correct because the earlobe is a well-vascularized and easily accessible area that provides accurate oxygen saturation measurements. Thickened toenails and edema of the hands might compromise readings in those locations.
Choice C rationale:
Applying the pulse oximeter probe to a skin fold is not a recommended site for oxygen saturation measurement. While there are various sites where pulse oximeters can be applied, the earlobe and finger are more suitable due to their consistent blood flow and accessibility.
Choice D rationale:
While applying the pulse oximeter probe to the finger is a common and acceptable practice, in this scenario, edema of the hands could affect the accuracy of the readings. The earlobe is a better choice as it is less likely to be affected by edema and can provide accurate readings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Re-measuring the respiratory rate is unnecessary. The reported respiratory rate falls within the normal range of 12-20 breaths per minute for adults.
Choice B rationale:
Re-measuring the temperature is the correct action. Tympanic temperature measurements can be influenced by factors such as earwax buildup, ear infection, or improper placement of the thermometer. Repeating the temperature measurement ensures accuracy.
Choice C rationale:
Re-measuring the pulse rate is unnecessary. The reported pulse rate of 92 beats per minute falls within the normal range of 60-100 beats per minute for adults.
Choice D rationale:
Re-measuring the blood pressure is unnecessary. The reported blood pressure of 88/58 mm Hg, while at the lower end of the normal range (typically around 90/60 mm Hg), is not excessively low and doesn't indicate an immediate need for concern.
Correct Answer is D
Explanation
Choice A rationale:
Sanguineous. Sanguineous drainage is typically bright red and consists of fresh blood. It indicates active bleeding from the wound. In this case, the drainage described is not bright red but rather light red-pink, suggesting that it is not purely sanguineous.
Choice B rationale:
Serous. Serous drainage is thin, watery, and typically clear or slightly yellowish in color. It is a normal part of the wound healing process and is not indicative of active bleeding. However, the drainage described in the question is light red-pink, which is not consistent with serous drainage.
Choice C rationale:
Purulent. Purulent drainage is thick, often opaque, and can range in color from yellow to green. It indicates the presence of infection in the wound. The description of watery light red-pink drainage does not align with the characteristics of purulent drainage.
Choice D rationale:
Serosanguineous. Serosanguineous drainage is a combination of serous and sanguineous fluids. It appears as a thin, watery drainage that is pink-tinged due to the presence of a small amount of blood. This description matches the observed drainage in the question. Serosanguineous drainage is common during the initial stages of wound healing and is considered a normal part of the process.
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