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","C","E"]

Explanation

Choice A rationale
Raised toilet seats are not a safety risk for older adults. In fact, they can help prevent falls in the bathroom by reducing the distance an individual has to move to sit down and stand up from the toilet.
Choice B rationale
Throw rugs are a safety risk for older adults. They can easily cause tripping and falling, especially if the edges are not secured.
Choice C rationale

A water heater temperature of 54.4°C (130° F) is a safety risk. Water at this temperature can cause burns, especially in older adults who may have decreased sensitivity to heat.
Choice D rationale
Bathtubs with rails are not a safety risk for older adults. Rails can provide support and stability when getting in and out of the bathtub, reducing the risk of falls.
Choice E rationale
Electric cords behind furniture are a safety risk. They can be a tripping hazard and can also pose a fire risk if they are damaged.

A. Check that three fingers will fit beneath the restraints. B. Retie the restraint straps with a slipknot. C. Retie the restraint straps to the side rails. D. Remove the padding under the wrist restraints.

Correct Answer is B

Explanation

Choice A rationale

While it is important to ensure that restraints are not too tight, the issue in this scenario is not related to the tightness of the restraints.
Choice B rationale
Restraints should be tied with a slipknot to allow for quick release if necessary. A double knot may be difficult to untie quickly in an emergency.
Choice C rationale
Restraint straps should not be tied to the side rails. If the side rails are lowered, the restraints could become too loose.
Choice D rationale
The padding under the wrist restraints should not be removed. The padding helps to prevent skin damage and increase the comfort of the patient.

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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

Naxlex Comprehensive Predictor Exams

A home health nurse is conducting a home-safety risk appraisal for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse has delegated the application of wrist restraints to an assistive personnel (AP) for a confused patient. The AP has padded the wrist restraints and secured the straps to the bed frame with a double knot. What action should the nurse take?

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?