A nurse is preparing to measure a client’s oxygen saturation and notes edema of the client’s hands and thickened toenails.
Where should the nurse apply the pulse oximeter probe?

Toe

Finger

Skin fold

Earlobe

Answer and Explanation

The Correct Answer is D

Choice A rationale
Applying the pulse oximeter probe to the toe might not provide an accurate reading if the client has poor peripheral circulation. Additionally, thickened toenails can interfere with the reading.
Choice B rationale

Edema in the hands can affect the accuracy of a pulse oximeter reading. The probe might not fit properly or provide a reliable reading if the finger is swollen.
Choice C rationale
Applying the pulse oximeter probe to a skin fold is not recommended. The probe needs to be placed on a relatively flat, thin area of skin to accurately measure oxygen saturation.
Choice D rationale
The earlobe is a suitable alternative site for pulse oximetry if the fingers and toes are not viable options. The earlobe is typically less affected by peripheral vasoconstriction, which can occur with hypothermia, certain medications, and certain diseases. Therefore, Choice D is the correct answer.

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Correct Answer is B

Explanation

Choice A rationale

The statement “The client should first move the strong leg then the weak one” is not the best practice when using a cane. The client should move the cane and the weak leg forward at the same time, then move the strong leg.
Choice B rationale
The statement “When the client moves, he should move the cane forward first” is the correct practice. Moving the cane first provides stability and support for the next step.
Choice C rationale
The statement “The client should hold the cane on the weak side of his body” is not the correct practice. The cane should be held on the strong side of the body to provide support for the weak side.
Choice D rationale
The statement “The grip should be level with the client’s waist” is a good practice, but it’s not the best answer for this question. The grip of the cane should be at the level of the client’s wrist when the client’s arm is hanging down. This allows the client to maintain a slight bend in their elbow when holding the cane.

A. Rapid respirations that are unusually deep and regular. B. An inability to breathe without dyspnea unless sitting upright. C. Breathing ranging from very deep to very shallow with periods of apnea. D. Shallow breathing alternating with periods of apnea.

Correct Answer is C

Explanation

Choice A rationale
Rapid respirations that are unusually deep and regular are not indicative of Cheyne-Stokes respirations. Cheyne-Stokes respirations are characterized by periods of apnea followed by gradually increasing then decreasing tidal volumes until another period of apnea.
Choice B rationale
An inability to breathe without dyspnea unless sitting upright is not indicative of Cheyne- Stokes respirations. This is more characteristic of orthopnea, which is commonly seen in conditions like heart failure.
Choice C rationale
Breathing ranging from very deep to very shallow with periods of apnea is indicative of Cheyne-Stokes respirations. This pattern of breathing is often seen in conditions such as heart failure, stroke, or brain damage.
Choice D rationale

Shallow breathing alternating with periods of apnea is not indicative of Cheyne-Stokes respirations. In Cheyne-Stokes respirations, the pattern of breathing includes periods of apnea followed by a gradual increase and then decrease in the depth of respirations.

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A nurse is preparing to measure a client’s oxygen saturation and notes edema of the client’s hands and thickened toenails. Where should the nurse apply the pulse oximeter probe?

Nursing Test Bank

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Correct Answer is B

Explanation

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A nurse is preparing to measure a client’s oxygen saturation and notes edema of the client’s hands and thickened toenails.
Where should the nurse apply the pulse oximeter probe?