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. While repositioning is important for comfort and preventing pressure ulcers, repositioning every 4 hours may not be sufficient, and it does not directly address the client's dyspnea.

B. Circulating air with a fan can help reduce the sensation of breathlessness and improve comfort for clients experiencing dyspnea. This non-invasive measure can be effective in relieving symptoms.

C. Placing the head of the bed flat is generally not recommended for clients with dyspnea, as it can worsen breathing difficulties. Elevating the head of the bed is usually more helpful.

D. Frequent oral care is important for maintaining comfort, especially in end-of-life care, but every 8 hours might not be sufficient. More frequent oral care is typically needed, and while important, this does not directly address dyspnea.

A. Prepare a dry work surface above the waist level. B. Open the outside cover of the sterile kit and remove the dust cover. C. Grasp the outermost flap of the sterile kit while opening away from the body. D. Open each side flap of the sterile kit individually while pulling to the side. E. Open the innermost lower flap of the sterile kit while standing away from the sterile field.

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

Explanation

To set up a sterile field for changing a dressing on an abdominal wound, the nurse should perform the following steps in sequence: First, prepare a dry work surface above waist level to ensure that the sterile field is maintained at a height that minimizes the risk of contamination. Next, open the outside cover of the sterile kit and carefully remove the dust cover, which protects the inner contents from contamination. Then, grasp the outermost flap of the sterile kit and open it away from the body, avoiding any abrupt movements that could compromise sterility. After that, open each side flap of the sterile kit individually, pulling them to the side and making sure not to reach over the sterile field. Finally, open the innermost lower flap of the sterile kit while standing away from the sterile field to prevent contamination from the nurse's clothing or body. These steps help maintain the sterility of the dressing and the instruments, which is crucial for preventing infection at the wound site.

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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 providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (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

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?

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