A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching?

Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds.

Use an adhesive oximetry probe for a client who has a latex allergy.

Remove polish from the client's fingernail before applying the oximetry probe.

Lubricate the tip of the oximetry probe.

Answer and Explanation

The Correct Answer is C

A.   Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds: Capillary refill time is not directly related to the placement of the pulse oximetry probe.
Capillary refill is assessed to evaluate peripheral perfusion.
B.   Use an adhesive oximetry probe for a client who has a latex allergy: The type of probe used for pulse oximetry is important, especially for clients with latex allergies. However, the correct action is to use a nonlatex probe or a probe that is compatible with the client's allergy, not necessarily an adhesive probe.
C.   Remove polish from the client's fingernail before applying the oximetry probe: Correct. Nail polish can interfere with the accuracy of pulse oximetry readings, as it may affect light transmission through the nail bed. It is essential to remove nail polish or artificial nails before applying the probe.
D.   Lubricate the tip of the oximetry probe: Lubricating the tip of the oximetry probe is not necessary for proper use and may interfere with the accuracy of readings.

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Correct Answer is A

Explanation

A. "Tell me what the afterlife means to you." Correct. This response demonstrates active listening and encourages the client to share their beliefs and feelings about the afterlife, providing the client with an opportunity for spiritual expression and understanding.
B. "You should discuss the afterlife with your priest." While discussing spiritual matters with a religious leader can be valuable, this response does not directly address the client's request for
the nurse to discuss the afterlife with them.
C. "Keep praying. A miracle could happen." This response may not fully address the client's need to discuss their beliefs about the afterlife. It focuses on hope but does not actively engage in the client's spiritual conversation.
D. "Maybe your condition will lead you closer to God." While offering comfort, this response may not meet the client's request to discuss the afterlife directly.

A. Show the assistive personnel where to apply the medication. B. Ask the client when the previous nurse last applied the medication. C. Identify the client by comparing the medication administration record with the client's room number. D. Compare the label of the medication container with the medication administration record three times.

Correct Answer is D

Explanation

A. Show the assistive personnel where to apply the medication: This action is not appropriate because only licensed healthcare providers, such as nurses, are allowed to administer
medications.
B. Ask the client when the previous nurse last applied the medication: While communication with the client is important, it is not a reliable method to verify medication administration accuracy.
C. Identify the client by comparing the medication administration record with the client's room number: This action is insufficient to verify the correct client because there could be multiple clients with the same medication due.
D. Compare the label of the medication container with the medication administration record three times: Correct. This action is known as the "three checks" and is an essential step in medication administration. The nurse should compare the medication label with the medication administration record before removing the medication, after removing the medication, and at the bedside before administering the medication.

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