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. Skin tenting occurs when the skin loses its elasticity due to dehydration. When gently pinched, the skin may remain elevated and return to its normal position slowly. This finding is a classic sign of dehydration and indicates that the client has lost significant fluid volume.
B. Elevated blood pressure (BP) can sometimes be associated with dehydration, especially in acute cases or when there are underlying conditions like hypovolemia. However, it is not typically a primary indicator of dehydration. Hypotension (low blood pressure) is more commonly associated with severe dehydration.
C. Red mucous membranes may indicate various conditions, including dehydration. Dehydration can lead to dryness and mucosal irritation, resulting in redness. However, red mucous membranes alone are not specific enough to reliably indicate dehydration without considering other signs and symptoms.
D. Jugular vein distention (JVD) is associated with fluid overload rather than dehydration. It occurs when there is increased pressure in the venous system, often due to heart failure or fluid retention. JVD is not typically seen in dehydrated individuals.
Correct Answer is B
Explanation
A. Performing a blind finger sweep involves inserting a finger into the client's mouth to try and remove an obstruction. This action is not recommended because it can push the obstruction further down the airway, potentially worsening the situation and causing the client to choke.
B. The Heimlich maneuver (abdominal thrusts) is a technique used to clear an obstructed airway in conscious adults. It involves applying sudden upward pressure on the abdomen, between the navel and ribcage, to force air from the lungs to dislodge the obstruction.
C. Turning the client to the side is typically done if the client is unconscious and not breathing normally (recovery position). This position helps maintain a clear airway by allowing any fluids or vomit to drain out of the mouth and prevent obstruction.
D. Tilting the head and lifting the chin is part of the head-tilt, chin-lift maneuver used to open the airway. This maneuver is used when a client is unconscious or unresponsive but breathing. It helps to keep the airway open by lifting the tongue away from the back of the
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