A nurse is instructing a newly licensed nurse on how to obtain a fecal occult blood test from a patient.
What information should the nurse include?

Choice A rationale:

The statement “The pulse oximeter may not be accurate during periods of excessive movement” is correct. Pulse oximeters measure the amount of oxygen in the blood by shining light through the skin, and movement can cause the light to scatter, leading to inaccurate readings.

Choice B rationale:

The statement “We will inform the doctor if the pulse oximeter consistently reads 100%” indicates further instruction is needed. A pulse oximeter reading of 100% is not necessarily a cause for concern. It simply means that the hemoglobin is fully saturated with oxygen. However, if the oxygen level is consistently at 100%, it could indicate that the oxygen flow is too high and needs to be adjusted. It’s important to follow the healthcare provider’s instructions regarding the desired oxygen saturation level for the infant.

Choice C rationale:

The statement “The probe of the pulse oximeter can be attached to a finger or a toe” is correct. The probe of a pulse oximeter can indeed be attached to a finger, toe, or even an earlobe. The important thing is that it’s attached to a part of the body with good blood flow. Choice D rationale:

The statement “We will move the probe of the pulse oximeter every 24 hours” is correct. It’s important to move the probe periodically to prevent skin damage, such as pressure sores or burns, especially in infants who have delicate skin.

Choice A rationale:

Taking the patient to the bathroom every 2 hours while the patient is awake is not the most effective strategy for a bowel training program. This approach does not take into account the natural rhythms of the body and the patient’s personal comfort. It may lead to unnecessary trips to the bathroom, which can be physically and emotionally draining for the patient.

Choice B rationale:

This is the correct answer. A bowel training program aims to help the patient regain control over their bowel movements. Taking the patient to the bathroom when they have the urge to defecate aligns with this goal. It allows the patient to respond to their body’s signals, which can help improve their confidence and independence over time.

Choice C rationale:

Taking the patient to the bathroom immediately before meals is not the most effective strategy for a bowel training program. While it’s true that eating can stimulate bowel movements due to the gastrocolic reflex, this approach does not consider the patient’s comfort or individual needs. It may also disrupt the patient’s enjoyment of their meals.

Choice D rationale:

Waiting until the patient feels abdominal cramping is not the most effective strategy for a bowel training program. Abdominal cramping can be a sign of constipation or other digestive issues. It’s important to address these issues separately and not rely on them as indicators for when to take the patient to the bathroom.