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 A
Explanation
A. Enteric-coated medications are designed to dissolve in the small intestine rather than the stomach. This is important for ileostomy patients because medications that dissolve in the stomach may be poorly absorbed or can cause irritation to the stoma or the small intestine.
B. It's recommended to empty the ostomy pouch when it's about one-third to half full to prevent leakage or discomfort.
C. How often the pouch system needs to be changed can vary depending on individual factors such as skin sensitivity, output consistency, and the type of pouch system used. Generally, changing the pouch system every 3-7 days is recommended.
D. High fiber foods can increase stool output and gas production, which can be challenging for individuals with an ileostomy. However, fiber is important for overall digestive health, so moderation rather than avoidance is typically recommended.
Correct Answer is A
Explanation
A. This temperature is slightly elevated (normal range is typically around 36.5-37.5°C or 97.7-99.5°F). While a mild temperature elevation could indicate infection or other underlying issues, it may not be immediately critical unless accompanied by other symptoms such as chills, increased heart rate, or signs of respiratory distress.
B. Hematocrit measures the proportion of red blood cells in the blood. A hematocrit of 45% is within the normal range for adults. However, changes in hematocrit levels over time can indicate fluid balance issues
or nutritional status, which are important to monitor but may not be an acute priority unless significantly abnormal.
C. A respiratory rate of 12 breaths per minute is within the normal range for adults. However, it's essential to consider if this rate is stable or if there are signs of respiratory distress such as increased effort or decreased oxygen saturation. Respiratory status should always be closely monitored, but a normal rate alone is not a priority concern.
D. Urine specific gravity measures the concentration of urine and can indicate hydration status. A specific gravity of 1.015 is within the normal range for urine concentration. However, changes in urine output or specific gravity can provide insights into fluid balance and renal function over time.
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