A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following actions should the nurse take?
Warm the infant's extremity for 1 min prior to placing the sensor probe.
Keep the infant's foot immobilized while the sensor is in place.
Place a sensor on the infant's index finger.
Place a sock over the infant's foot to secure the sensor.
The Correct Answer is B
A. Warm the infant's extremity for 1 min prior to placing the sensor probe: While cold extremities can affect pulse oximetry readings, brief warming alone may not reliably improve accuracy. Proper probe placement and minimizing movement are more critical to obtaining consistent readings.
B. Keep the infant's foot immobilized while the sensor is in place: Immobilizing the extremity prevents motion artifact, which can interfere with pulse oximetry accuracy. This is a recommended action for continuous monitoring in infants, as movement can cause false low or fluctuating readings.
C. Place a sensor on the infant's index finger: In infants, the fingers are often too small for standard pulse oximetry probes. Preferred sites include the foot or wrist, which accommodate the sensor without compromising accuracy.
D. Place a sock over the infant's foot to secure the sensor: Covering the sensor with a sock may create pressure or interfere with proper probe function, and it can trap moisture, which affects readings. Securing the probe with gentle adhesive or specialized wraps is safer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A client who is 2 days postoperative following a colon resection: This client may have complex postoperative needs, including management of surgical drains, potential complications such as infection or anastomotic leakage, and advanced pain management. These require specialized knowledge and experience, making it less appropriate for a float nurse.
B. A client who has tuberculosis and is on airborne precautions: Care for a client with airborne precautions requires strict adherence to infection control protocols, including use of negative pressure rooms and N95 respirators. A float nurse from postpartum may not be fully trained in airborne isolation procedures, making this assignment unsafe.
C. A client who has a head injury and requires neurological checks every 4 hr: Frequent neurological assessments and the ability to detect subtle changes in neuro status require specialized knowledge and experience in neuro care. A float nurse from postpartum may not have the necessary training to safely monitor and respond to neurological changes.
D. A client who is 1 day postoperative following a transurethral resection of the prostate: This client typically requires routine postoperative monitoring, including vital signs, intake and output, and catheter care, which are within the skill set of a float nurse with general nursing experience. The care is predictable and does not require specialized care knowledge.
Correct Answer is C
Explanation
A. Varicella zoster: Varicella (chickenpox) is transmitted via airborne and contact routes. Airborne precautions with a negative-pressure room are required, not droplet precautions.
B. Vancomycin-resistant enterococcus (VRE): VRE is primarily spread via contact with contaminated surfaces or hands. Contact precautions are indicated, rather than droplet precautions.
C. Pertussis: Pertussis (whooping cough) is transmitted via respiratory droplets. Droplet precautions, including a mask for close contact, are essential to prevent spread to healthcare personnel and other clients.
D. Rotavirus: Rotavirus is transmitted primarily via the fecal-oral route. Contact precautions are necessary to prevent spread, not droplet precautions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.