A nurse is obtaining an oxygen saturation on a client.
Which of the following actions should the nurse take?
Relocate the sensor every 8 hrs.
Wait 10 sec after placing the probe before obtaining the oxygen saturation reading.
Choose a finger with a capillary refill less than 2 sec.
Place the sensor probe on the same extremity as an electronic blood pressure cuff.
The Correct Answer is C
Choice A rationale:
Relocating the sensor every 8 hours is not necessary when obtaining oxygen saturation readings unless there is a specific clinical reason to do so, such as skin irritation or poor perfusion at the sensor site. Frequent relocation can cause unnecessary disruption for the patient.
Choice B rationale:
Waiting 10 seconds after placing the probe before obtaining the oxygen saturation reading is not required. Modern pulse oximeters provide real-time readings, and there is no need to wait after placing the probe. The reading is usually stable within seconds.
Choice C rationale:
Choosing a finger with a capillary refill time of less than 2 seconds is an essential consideration when obtaining oxygen saturation readings. Capillary refill time is a measure of peripheral perfusion, and choosing a finger with good perfusion ensures accurate oxygen saturation measurements.
Choice D rationale:
Placing the sensor probe on the same extremity as an electronic blood pressure cuff is generally acceptable. However, it is crucial to ensure that the sensor does not interfere with the blood pressure cuff's function and that it is securely attached to the patient's finger for accurate readings.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
An entry on a nursing blog, while potentially informative, does not provide the same level of evidence-based information as a peer-reviewed journal article. Blog posts may not undergo rigorous peer review and may lack the scientific rigor and credibility associated with peer-reviewed research. Therefore, choice A is not the best source for evidence-based information.
Choice B rationale:
Information from a wound care product vendor may be biased and influenced by commercial interests. Vendors often aim to promote their products, and the information they provide may not be impartial or based on rigorous scientific research. Therefore, choice B is not the best source for evidence-based information.
Choice C rationale:
A peer-reviewed journal article is considered one of the most reliable sources of evidence-based information in healthcare. Such articles undergo a thorough review process by experts in the field to ensure the accuracy, quality, and validity of the research findings. Peer-reviewed articles provide credible and up-to-date information based on scientific research and are widely recognized as a gold standard in evidence-based practice. Therefore, choice C is the correct answer as it offers the best evidence-based information.
Choice D rationale:
First-hand experience with wound care products, while valuable, may not necessarily provide the most comprehensive or up-to-date information. Personal experiences can vary, and healthcare practices evolve over time based on research and new evidence. Therefore, choice D is not the best source for evidence-based information.
Correct Answer is C
Explanation
Choice A rationale:
"Apply fundal pressure during contractions." - Applying fundal pressure during contractions is not appropriate during the latent stage of labor. Fundal pressure is typically used during the second stage of labor (active pushing phase) to assist with fetal descent. Using it during the latent stage can be harmful.
Choice B rationale:
"Encourage the client to soak in a hot bath." - Soaking in a hot bath is generally not recommended during labor, especially without specific indications. It is essential to maintain the safety and well-being of both the mother and the baby. Encouraging the client to change positions or use comfort measures like relaxation techniques would be more appropriate.
Choice C rationale:
"Instruct the client to change positions frequently." - This is the correct answer. During the latent stage of labor, encouraging the client to change positions frequently can help promote comfort and optimize fetal positioning. Changing positions can reduce discomfort, enhance uterine contractions, and facilitate the progression of labor.
Choice D rationale:
"Tell the client to push during contractions." - Pushing during contractions is typically reserved for the second stage of labor when the cervix is fully dilated. In the latent stage, the cervix is not fully dilated, and pushing prematurely can be harmful and delay labor progress. It is essential to follow the appropriate guidelines for each stage of labor.
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