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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A rationale:

This is the correct answer. Older adults often experience decreased kidney function as a normal part of aging. Medications that are excreted primarily by the kidneys may require dosage adjustments to prevent potential toxicity.

Choice B rationale:

Increased liver function is not a typical physiological change in older adults. Liver function tends to decrease with age, which can affect the metabolism and clearance of certain medications.

Choice C rationale:

Increased metabolism is not a common physiological change in older adults. Metabolic rate tends to decrease with age, which can affect the metabolism of drugs.

Choice D rationale:

While pulmonary function may decrease with age, it is not the primary physiological change to consider when administering medications to older adults. Kidney function is a more critical factor in medication dosing for this population.

A. Bradycardia. B. Anorexia. C. Weight gain. D. Epistaxis.

Correct Answer is D

Explanation

Choice A rationale:

Bradycardia. Heparin is an anticoagulant medication that primarily affects the blood's clotting ability. Bradycardia, or a slow heart rate, is not a common side effect of heparin. Therefore, it is not a typical adverse effect to report in this context.

Choice B rationale:

Anorexia. Anorexia, or a loss of appetite, is not a common adverse effect of heparin. Heparin's primary mode of action is to prevent blood clot formation, and it does not directly affect appetite.

Choice C rationale:

Weight gain. Weight gain is not a typical adverse effect of heparin. Heparin's mechanism of action does not lead to changes in body weight. Weight gain could be related to other factors but is not directly associated with heparin administration.

Choice D rationale:

Epistaxis. Epistaxis, or nosebleeds, can be a sign of a bleeding disorder or an adverse effect of anticoagulant therapy like heparin. Heparin can increase the risk of bleeding, including nosebleeds, and should be monitored closely for this adverse effect. It is important to report any signs of excessive bleeding to the healthcare provider as they may need to adjust the dosage or monitor the patient more closely.

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A nurse is obtaining an oxygen saturation on a client.
Which of the following actions should the nurse take?