A nurse is planning to obtain a client's oxygen saturation. Which of the following might influence the result of this test?

The client is wearing nail polish.

The client has an elevated hemoglobin level.

The client has a fever.

The client is wearing a ring.

Answer and Explanation

The Correct Answer is A

A. Nail polish can interfere with the accuracy of pulse oximetry readings by absorbing or

reflecting light, leading to falsely low oxygen saturation readings. It's essential to remove nail polish or acrylic nails from the finger used for pulse oximetry to obtain accurate results.
B.   While an elevated hemoglobin level may affect the oxygen-carrying capacity of the blood, it does not directly influence the accuracy of pulse oximetry readings.

C.   Fever may affect oxygen saturation levels indirectly by increasing metabolic demand or
respiratory rate, but it does not directly interfere with the accuracy of pulse oximetry readings.
D.   Wearing a ring does not typically interfere with pulse oximetry readings unless the ring is very tight and impairs blood flow to the finger. However, nail polish is a more significant
concern for accurate readings.

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Correct Answer is B

Explanation

A. Placing unnecessary sterile items on the field is not ideal, but it does not indicate contamination of the surgical field.

B. Pouring sterile solution with the bottle held over the field is an inappropriate technique since it breaches the sterility of the field.

C. The handle of a pair of sterile scissors resting 5 cm (2 in) from the field's edge does not indicate contamination of the surgical field. The scissors should be placed within easy reach of the nurse but should not touch non-sterile items.

D. Allowing sterile forceps to rest in a container of sterile does not affect the sterility of the field.

A. Secure the restraints with a square knot. B. Check the client's range of motion every 6 hr. C. Make sure two fingers fit under the restraints. D. Request a prescription renewal from the provider every 36 hr.

Correct Answer is C

Explanation

A. Securing the restraints with a square knot may be too tight and could restrict circulation or cause injury. Using a quick-release knot is preferable to allow for quick removal if necessary.
B. While it is important to assess the client's range of motion regularly, this action does not directly address the proper application of the restraints.

C. This is the correct action to ensure that the restraints are not too tight, allowing for adequate circulation and preventing injury. The ability to fit two fingers under the restraints ensures that they are applied with proper tension.
D. Requesting a prescription renewal from the provider every 36 hours may be necessary according to facility policy, but it does not directly address the proper application of the
restraints.

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A nurse is planning to obtain a client's oxygen saturation. Which of the following might influence the result of this test?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?

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Explanation

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Correct Answer is C

Explanation

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