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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Severe wheezing indicates a potential allergic reaction or anaphylaxis to the IV antibiotics, which requires immediate intervention. It can compromise the client's respiratory function and may lead to respiratory arrest if not promptly addressed.
B. Rhinitis, or inflammation of the nasal passages, is not typically associated with IV antibiotic administration and is not a life-threatening emergency.
C. Small, raised vesicles over the body may indicate a rash or allergic reaction, but unless accompanied by other severe symptoms such as difficulty breathing or systemic signs of anaphylaxis, it does not require immediate reporting.
D. Itching of the skin may indicate a mild allergic reaction, but unless accompanied by more severe symptoms, it does not require immediate reporting.
Correct Answer is C
Explanation
A. Applying talc powder around the stoma can prevent the appliance from adhering properly, leading to leakage. It is not recommended for ostomy care.
B. The skin barrier should be cut to fit closely around the stoma, leaving no more than a 1/8 inch gap, not 1/2 inch. A larger opening may cause skin irritation or leakage.
C. Pressing on the skin barrier for about 30 seconds ensures that it adheres properly to the skin, which helps secure the ostomy appliance and prevents leakage.
D. Moisturizing soap is not recommended for cleaning around the stoma, as it can leave a residue that interferes with the appliance's adhesion. Mild soap without moisturizers or just water should be used.
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