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 ["2"]
Explanation
To administer the correct dose of levothyroxine, which is 100 mcg, the nurse would need to give two tablets of the 50 mcg dosage.
Correct Answer is A
Explanation
A. Repositioning the client regularly is a critical measure to prevent pressure ulcers. This helps relieve pressure on vulnerable areas of the body and improves circulation. Turning the client every 2 hours is a common guideline to prevent prolonged pressure on any one area.
B. Keeping the head of the bed elevated continuously is not recommended as it can increase shear and friction, leading to skin breakdown.
C. Keeping the client's skin moisturized is important for maintaining skin integrity, but excessive moisture can increase the risk of skin breakdown, especially in areas susceptible to pressure ulcers. The nurse should aim to keep the skin clean, dry, and free from excessive moisture to prevent maceration.
D. Massaging bony prominences is not recommended as a preventive measure for pressure ulcers. In fact, massaging these areas can increase the risk of tissue damage due to friction and shearing forces. The focus should be on relieving pressure through proper positioning and support surfaces rather than massage.
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