A nurse is preparing to measure a client's oxygen saturation and notes edema of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?
Toe
Skin fold
Earlobe
Finger
The Correct Answer is C
A. The toe could also be affected by the edema leading to inaccurate reading.
B. Placing the pulse oximeter probe on a skin fold is not recommended. Skin folds can obscure proper positioning of the probe and interfere with accurate readings. Additionally, skin folds may not adequately represent blood flow and oxygenation levels compared to other sites.
C. This location is recommended because it is usually free of the issues that can affect the extremities, such as poor circulation or changes in peripheral perfusion, and can provide a more reliable saturation reading.
D. The finger is the most common site for applying a pulse oximeter probe due to its accessibility and reliability. However, in cases where the fingers are not suitable, such as when there is significant edema or thickened toenails, alternative sites like the toe may be preferred.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The oliguric phase of AKI typically lasts longer than 2 days. It can extend from several days to weeks, depending on the underlying cause and the response to treatment.
B. During the oliguric phase of AKI, urine output is significantly reduced. Typically, urine output is less than 400 mL per day, but it can vary widely based on the severity of kidney injury and individual factors.
C. The oliguric phase of AKI usually begins within a few days to a week after the initial injury. It is characterized by a sudden decrease in urine output and may be accompanied by electrolyte imbalances and fluid overload.
D. During the oliguric phase of AKI, there is typically a buildup of waste products such as blood urea nitrogen (BUN) and creatinine in the blood. These levels rise because the kidneys are unable to effectively filter and excrete waste products. Therefore, BUN and creatinine levels usually increase during the oliguric phase.
Correct Answer is A
Explanation
A. A stage 3 pressure ulcer is characterized by full-thickness skin loss that may extend into the subcutaneous tissue layer but does not involve exposure of muscle, tendon, or bone. The ulcer appears as a deep crater, and there may be damage to the surrounding tissue as well.
B. This describes a stage 1 pressure ulcer. Stage 1 ulcers involve intact skin with non-blanchable redness, indicating potential damage to underlying tissue.
C. This describes a stage 2 pressure ulcer. Stage 2 ulcers involve partial-thickness loss of skin involving the epidermis and/or dermis, presenting as a shallow open ulcer or intact blister.
D. Accurately describes a stage 4 pressure ulcer.
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