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 D

Explanation

Choice A rationale:

Asking, "What would your family do without you?" can be seen as judgmental and may not encourage open communication. It doesn't directly address the client's statement about feeling like a burden or wanting to be gone.

Choice B rationale:

Saying, "When you get better you will not feel this way," minimizes the client's feelings and can be invalidating. It does not show empathy or concern for the client's current emotional state.

Choice C rationale:

Asking, "Why would you think a thing like that?" can come across as judgmental and may make the client defensive. It does not directly address the client's emotional distress or suicidal ideation.

Choice D rationale:

This is the correct answer. "Are you thinking of hurting yourself?" is a direct and appropriate question to assess the client's risk of self-harm or suicide. It demonstrates concern for the client's well-being and opens the door for a more in-depth conversation about their feelings and thoughts. Assessing for suicidal ideation is a crucial step in providing appropriate care for a client with depressive disorder.

A. Hypertension. B. Constipation. C. Muscle cramps. D. Blurred vision.

Correct Answer is C

Explanation

Choice A rationale:

Hypertension (high blood pressure) is not typically associated with hyponatremia. Hyponatremia is characterized by low levels of sodium in the blood, which can lead to symptoms such as headache, nausea, vomiting, confusion, and muscle cramps. Hypertension is more commonly associated with conditions like hypertension itself or conditions that cause fluid retention.

Choice B rationale:

Constipation is not a typical finding in hyponatremia. Hyponatremia is more likely to cause gastrointestinal symptoms such as nausea and vomiting. Constipation is not a direct consequence of low sodium levels in the blood.

Choice C rationale:

Muscle cramps are a common manifestation of hyponatremia. Low sodium levels can lead to an imbalance in electrolytes, affecting muscle function and leading to muscle cramps and weakness. Monitoring for muscle cramps is important in clients with hyponatremia.

Choice D rationale:

Blurred vision is not a classic symptom of hyponatremia. Hyponatremia is more likely to cause neurological symptoms such as confusion, headache, and in severe cases, seizures. Blurred vision is typically associated with other eye or visual disorders and not directly related to low sodium levels in the blood.

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