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 C

Explanation

Answer isc. Keep the head of the bed raised while the tube feeding is infusing.

The client has a gastrostomy tube (GT), which is a tube inserted through the abdomen into the stomach for feeding purposes1.The PN should instruct the UAP to keep the head of the bed raised at least 30 degrees while the tube feeding is infusing, to prevent aspiration of the feed into the lungs2.Aspiration can cause pneumonia, which is a serious complication that can be fatal3.

a. Raising the entire bed while bathing the client to reduce back strain is not the most important instruction, because it does not address the risk of aspiration. The PN should also consider the client’s comfort and safety when adjusting the bed height. b. Reporting any drainage observed around the GT insertion site is not the most important instruction, because it is not directly related to the tube feeding. Drainage may indicate infection or leakage of the feed, which should be reported and managed accordingly. d. Using plenty of pillows to position the client on the side after bathing is not the most important instruction, because it is not specific to the tube feeding. Positioning the client on the side may help prevent pressure ulcers and improve circulation, but it does not prevent aspiration.

A. The client has developed difficulty ambulating. B. The client's next dressing change is scheduled in 4 hr. C. The client has state-sponsored health insurance. D. The client's vital signs are checked every 8 hr.

Correct Answer is A

Explanation

Choice A rationale:

In an interprofessional team meeting for a client, it is essential to include information about changes in the client's condition or any new developments that may impact their care. The statement that "The client has developed difficulty ambulating" is relevant as it indicates a change in the client's mobility status and may require additional interventions or assessments.

Choice B rationale:

The timing of the client's next dressing change (scheduled in 4 hr) is important information but may not be the highest priority to discuss in an interprofessional team meeting. It is more pertinent to focus on the client's current condition and any changes that have occurred.

Choice C rationale:

The client's health insurance status (state-sponsored health insurance) is not typically a central topic of discussion in an interprofessional team meeting unless it directly affects the client's care plan or access to specific treatments.

Choice D rationale:

The frequency of the client's vital sign checks (every 8 hr) is important information for the healthcare team to be aware of, but it may not be the most critical piece of information to include in the interprofessional team meeting. Changes in vital signs or trends would be more relevant to discuss.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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