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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The Heelis not in direct contact with the bed surface when a client is in the prone position. Therefore, a pillow is not typically needed to relieve pressure in this area.
The coccyx, or tailbone, is not in direct contact with the bed surface when a client is in the prone position. Therefore, a pillow is not typically needed to relieve pressure in this area.
The Occiput, is not in direct contact with the bed surface when a client is in the prone position. Therefore, a pillow is not typically needed to relieve pressure in this area.
he breasts, particularly in female clients, can experience significant pressure when in the prone position. Using a small pillow can help to relieve this pressure and increase the client’s comfort.A small pillow can help support the client’s breasts and prevent them from being compressed or injured during the prone position1.The breasts are a sensitive area that can be affected by gravity, friction, or pressure2.A pillow can also help maintain proper body alignment and prevent hyperextension of the back
Correct Answer is C
Explanation
Choice A rationale:
Hypercalcemia. Hypercalcemia refers to an elevated level of calcium in the blood. It is not typically a concern in a newborn, and monitoring for hypercalcemia is not necessary in this context. The infant's weight and maternal diabetes are more relevant factors to consider.
Choice B rationale:
Hypobilirubinemia. Hypobilirubinemia implies a low level of bilirubin in the blood, which is not a common concern in newborns, especially in the context of a newborn's weight and maternal diabetes. Monitoring for hyperbilirubinemia, which can lead to jaundice, would be more appropriate.
Choice C rationale:
Hypoglycemia. Hypoglycemia, or low blood sugar, is a significant concern in newborns of diabetic mothers. Newborns born to diabetic mothers are at increased risk of hypoglycemia due to the abrupt cessation of the continuous glucose supply from the mother's bloodstream after birth. Monitoring the newborn's blood glucose levels is crucial in this case.
Choice D rationale:
Decreased RBC. Monitoring for decreased red blood cell (RBC) counts is not typically a primary concern in a newborn, especially one born to a diabetic mother. Hypoglycemia, which can be a result of maternal diabetes, poses a more immediate and significant threat to the newborn's well-being.
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