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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Precontemplation
According to evidence-based practice, the nurse should identify that precontemplation is the first stage the client will experience when using the stages of health behavior change. In this stage,
the client avoids discussing the behavior and does not intend to make a change in behavior. The stages of health behavior change are pre contemplation, contemplation, preparation, action and the maintenance stage
B. Preparation INCORRECT
The nurse should identify that preparation is the third stage the client will experience when using the stages of health behavior change. In this stage, the client plans to make minor changes to behavior. However, according to evidence-based practice, another stage occurs prior to the preparation stage.
Correct Answer is B
Explanation
A) Autonomy refers to the right of the client to make their own decisions about their care. In this scenario, the nurse respects the client's decision not to take the pill as it is, but does not stop there.
B) Beneficence is the principle of doing good and acting in the best interest of the client. By offering to break the pill, the nurse is actively seeking a solution to ensure the client receives the necessary medication, which is in the client's best interest.
C) Justice relates to fairness and the equal distribution of resources. While important, it is not the primary principle being demonstrated in this situation.
D) Nonmaleficence means to do no harm. Although breaking the pill could be seen as avoiding harm by preventing the client from choking, it is more about ensuring the client's treatment continues effectively, which aligns more closely with beneficence.
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