A client asks a nurse, “Why do I have to remove my nail polish in order for my pulse oximetry to be monitored?” Which is the best response by the nurse?
“I need to be able to assess the color of your nailbed.”.
“Nail polish can interfere with the transmission of light waves.”.
“The sensor may react with the nail polish causing an allergic reaction.”.
“The chemicals in the nail polish can cause falsely decreased readings of your oxygen level.”.
The Correct Answer is B
Pulse oximetry works by measuring the amount of light that passes through your finger and reaches a sensor on the other side.
The amount of light that is absorbed by your blood depends on how much oxygen it carries. Nail polish can block or reflect some of the light, making it harder for the pulse oximeter to get an accurate reading of your oxygen level.
Choice A is wrong because the color of your nailbed is not relevant for pulse oximetry.
The pulse oximeter does not measure the color of your nailbed, but the amount of light that passes through it.
Choice C is wrong because the sensor does not react with the nail polish causing an allergic reaction.
The sensor is a non-invasive device that does not touch your skin or nail polish directly.
Choice D is wrong because the chemicals in the nail polish do not cause falsely decreased readings of your oxygen level.
The chemicals in the nail polish do not affect the amount of oxygen in your blood, but only the amount of light that reaches the sensor.
Normal ranges for pulse oximetry vary depending on your health condition and altitude, but generally they are between 95% and 100%. If your pulse oximetry reading is lower than 90%, you may have hypoxia, which means your tissues are not getting enough oxygen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This outcome indicates that the client has resolved their constipation and has a regular pattern of defecation without difficulty or discomfort.
Choice A is wrong because taking a laxative daily can worsen constipation by causing dependency and reducing the natural peristalsis of the colon.
Choice C is wrong because requesting a bedpan every four hours does not necessarily mean that the client has bowel movements. It may indicate that the client has difficulty passing stool or has a sensation of incomplete emptying.
Choice D is wrong because having a bowel movement within 72 hours is still considered constipation. Constipation is diagnosed when bowel movements are associated with at least two of the following symptoms, occurring in the past three months with an onset of symptoms of at least six months: Less than three spontaneous bowel movements per week, Lumpy or hard stools from at least 25% of bowel movements.
Correct Answer is D
Explanation
Cleanse from the innermost point outwards with a circular movement. This technique reduces the risk of contaminating the wound with bacteria from the surrounding skin.
Some possible explanations for the other choices are:
Choice A is wrong because hydrogen peroxide and betadine solution can damage healthy tissue and delay wound healing.
Choice B is wrong because cleansing the wound from the outer edges towards the center can introduce bacteria from the skin into the wound.
Choice C is wrong because using 4x4 gauze to the wound and surrounding skin three times can cause trauma and bleeding to the wound.
Normal ranges for pressure ulcer stages are:
- Stage I: A reddened, painful area on the skin that does not turn white when pressed.
- Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.
- Stage III: The skin develops an open, sunken hole called a crater or ulcer. The tissue below the skin is damaged.
- Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.
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