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:

"Nervousness." Rationale: This is a correct instruction. Thyrotoxicosis is a condition characterized by excessive thyroid hormone production. Common symptoms include nervousness, anxiety, restlessness, and emotional instability. The client should notify the healthcare provider if they experience these symptoms as they may indicate an excessive dose of levothyroxine.

Choice B rationale:

"Cough." Rationale: Cough is not typically associated with thyrotoxicosis. Symptoms of thyrotoxicosis are primarily related to an overactive thyroid gland and may include palpitations, weight loss, heat intolerance, and nervousness.

Choice C rationale:

"Pruritus." Rationale: Pruritus (itching) is not a common symptom of thyrotoxicosis. Itchy skin is more likely related to other dermatological or systemic conditions and should be evaluated separately.

Choice D rationale:

"Polyuria." Rationale: Polyuria (excessive urination) can be associated with both hypothyroidism and hyperthyroidism, but it is not a typical manifestation of thyrotoxicosis. Increased urination is more commonly seen in conditions like diabetes mellitus. Therefore, polyuria alone may not be indicative of thyrotoxicosis in this context.

A. An entry on a nursing blog addressing wound healing. B. Information from a wound care product vendor. C. A peer-reviewed journal article. D. First-hand experience with wound care products.

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.

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Nursing Test Bank

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