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 B
Explanation
Choice A rationale:
Hydrogen peroxide. Hydrogen peroxide is not the recommended solution for disinfecting surfaces following a blood spill. While it can be used to clean wounds and may have some disinfectant properties, it is not as effective as bleach in destroying bloodborne pathogens.
Choice B rationale:
Bleach. Bleach is the appropriate choice for disinfecting surfaces contaminated with blood. A 10% bleach solution (1 part bleach to 9 parts water) is effective at killing bloodborne pathogens such as HIV and hepatitis B and C viruses. It should be used in healthcare settings to ensure proper disinfection after a blood spill.
Choice C rationale:
Isopropyl alcohol. Isopropyl alcohol is an effective disinfectant for some purposes, but it may not be as effective as bleach against bloodborne pathogens. It is commonly used for cleaning and disinfecting skin before medical procedures but is not the recommended choice for disinfecting surfaces following a blood spill.
Choice D rationale:
Chlorhexidine. Chlorhexidine is an antiseptic solution often used for skin disinfection before surgical procedures or invasive medical interventions. It is not typically used for disinfecting surfaces contaminated with blood.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should respond by offering to show the client how to swaddle and cuddle the newborn and then encourage the client to try it herself. This response promotes bonding between the mother and newborn and empowers the client to care for her baby, building her confidence and self-esteem.
Choice B rationale:
Taking the newborn back to the nursery without involving the mother does not support maternal-infant bonding and does not address the client's feelings of inadequacy. It is essential to encourage maternal involvement in infant care.
Choice C rationale:
Turning the newborn on his side without addressing the client's concerns does not provide emotional support or guidance on infant care. It is important to respond to the client's emotional needs and offer assistance in caring for the baby.
Choice D rationale:
Telling the client that babies need to cry to develop their lungs is not an appropriate response to the client's distress. It does not address the client's concerns or provide helpful guidance on caring for the newborn.
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