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 B

Explanation

A. Discontinued medications are documented in the medical record but are not the primary focus of the transfer report.
B. Resolved health conditions should be included in the transfer report so the receiving facility has a clear understanding of the client’s current health status and any changes in care needs.
C. Frequency of vital sign collection is part of ongoing care but is not the most critical information to communicate during transfer.
D. Completed nursing interventions are documented in the record but do not need to be emphasized in the transfer report.

A. Place the client's medication record on the bedside table while ambulating the client. B. Give a report about the client's status while standing at the nurses' station. C. Speak with the client about their condition after visitors have left. D. Place a message board in the client's room to post dietary information.

Correct Answer is C

Explanation

A. Place the client's medication record on the bedside table while ambulating the client: This action does not relate to protecting the client's privacy. It might actually compromise confidentiality by leaving sensitive information exposed.

B. Give a report about the client's status while standing at the nurses' station: This action does not protect the client's privacy. Discussing sensitive information in a public area can lead to breaches of confidentiality.

C. Speak with the client about their condition after visitors have left: Correct. Protecting the client's privacy is essential, and discussing personal health information in private with the client respects their right to confidentiality.

D. Place a message board in the client's room to post dietary information: This action does not relate to protecting the client's privacy. Posting dietary information may be helpful for staff, but it doesn't address the client's privacy concerns.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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