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","C","D","E"]
Explanation
Choice A rationale:
This choice is not correct because verifying the oxygen flow rate every other day is not part of the discharge teaching for a client on home oxygen therapy. The flow rate should be checked regularly, not just every other day, to ensure the client's safety and well-being.
Choice B rationale:
This choice is correct. Checking the tops of the ears for skin breakdown is important in a client using a nasal cannula for oxygen therapy. Prolonged use of the cannula can lead to irritation and pressure-related skin breakdown behind the ears.
Choice C rationale:
This choice is correct. Posting "no smoking signs in a prominent location in the home" is an important safety measure for a client on oxygen therapy. Oxygen supports combustion, and smoking in the presence of oxygen can lead to fire hazards.
Choice D rationale:
This choice is correct. Checking the cannula position on a regular basis is essential to ensure that the oxygen is being delivered effectively and that the client is not experiencing discomfort or skin breakdown due to improper positioning.
Choice E rationale:
This choice is correct. Applying petroleum ointment to the nares if they become dry and irritated is a suitable intervention to maintain the client's comfort and prevent skin irritation from the cannula.
Correct Answer is B
Explanation
Choice A rationale:
Autonomy refers to a patient's right to make their own decisions about their medical care. While autonomy is an important ethical principle, it is not directly related to the situation described. The nurse providing oxygen therapy to the patient without the patient's consent is not an example of respecting autonomy.
Choice B rationale:
Beneficence is the correct choice. Beneficence is the ethical principle of doing what is best for the patient's well-being. In this situation, providing oxygen therapy to a patient experiencing difficulty in breathing aligns with the principle of beneficence. Oxygen therapy aims to improve the patient's oxygenation and alleviate respiratory distress.
Choice C rationale:
Veracity refers to truthfulness and honesty in communication. While honesty is important, it is not the primary ethical principle at play in this situation. Providing oxygen therapy to improve the patient's condition is more aligned with beneficence.
Choice D rationale:
Fidelity refers to the duty to be faithful and keep promises. While fidelity is important in maintaining trust between healthcare providers and patients, it is not the primary principle relevant here. The priority is to address the patient's immediate health needs through appropriate interventions like oxygen therapy.
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