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. Headache can be a common side effect of blood transfusion but is not typically considered an urgent or life-threatening complication requiring immediate reporting.
B. Dyspnea (difficulty breathing) can indicate a serious transfusion reaction such as transfusion- related acute lung injury (TRALI) or circulatory overload and should be reported immediately to the provider for further evaluation and intervention.
C. Hyperthermia (elevated body temperature) may indicate a febrile reaction to the transfusion but is not as immediately life-threatening as dyspnea.
D. Urticaria (hives) is a common allergic reaction to blood transfusion but is not typically considered as urgent or life-threatening as dyspnea.

A. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin. B. Unlock and remove the inner cannula. C. Scrub the inside and outside of the inner cannula with a small brush. D. Wipe the inside of the inner cannula with a folded pipe cleaner. E. Cleanse the stoma site with 0.9% sodium chloride solution.

Correct Answer is A,B,C,D,E

Explanation

Pouring 0.9% sodium chloride solution into the sterile basin provides the solution necessary for cleaning the inner cannula.

Unlocking and removing the inner cannula is the first step in the process of tracheostomy care.

Scrubbing the inside and outside of the inner cannula with a small brush helps remove secretions and debris.

Wiping the inside of the inner cannula with a folded pipe cleaner further cleans the inner surfaces.

Cleansing the stoma site with 0.9% sodium chloride solution completes the tracheostomy care procedure.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?

Correct Answer is B

Explanation

48. A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A,B,C,D,E

Explanation

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