A nurse is preparing to obtain the oxygen saturation of a client who has peripheral edema and thickened toenails. Which of the following actions should the nurse take?

Attach a probe carefully to the client's finger to prevent discomfort.

Apply a sensor pad to the client's forehead.

Secure a probe to one of the client's toes.

Obtain a pulse oximetry reading when peripheral edema has decreased.

Answer and Explanation

The Correct Answer is B

A. Attach a probe carefully to the client's finger to prevent discomfort. Peripheral edema may impair circulation, leading to inaccurate readings.

B. Apply a sensor pad to the client's forehead. The forehead provides a more accurate reading when peripheral circulation is compromised.

C. Secure a probe to one of the client's toes. Thickened toenails and edema may interfere with an accurate reading.

D. Obtain a pulse oximetry reading when peripheral edema has decreased. The nurse should not delay obtaining an oxygen saturation reading if an alternative site is available.

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Correct Answer is A

Explanation

A. Nausea: Nausea is a sign of intolerance to enteral feedings and may indicate delayed gastric emptying or feeding that is too rapid. The nurse should slow the rate of feeding, assess for abdominal distention, and check for residual volume.

B. Urine output 40 mL/hr: Urine output of 40 mL/hr is within the normal range (≥30 mL/hr) and does not indicate intolerance to enteral feedings. However, a significant decrease in urine output (oliguria) could indicate dehydration or kidney issues.

C. Soft stools: Soft stools can be a normal response to enteral feedings unless the client develops diarrhea. Watery, frequent stools may indicate malabsorption, but soft stools alone are not a sign of feeding intolerance.

D. Headache: Headaches are not a common symptom of enteral feeding intolerance. They may be related to other issues such as dehydration, hypertension, or medication side effects.

A. Provide the client with a referral to a support group. B. Encourage the client to view the body of their partner. C. Reinforce the need for the client to build new relationships. D. Encourage the client to share their thoughts and feelings.

Correct Answer is D

Explanation

A. Provide the client with a referral to a support group. Not the first priority; occurs later in the grieving process.

B. Encourage the client to view the body of their partner. Only appropriate if the client wants to do so.

C. Reinforce the need for the client to build new relationships. Insensitive and premature during initial grief.

D. Encourage the client to share their thoughts and feelings. Therapeutic communication is the first step in grief support, allowing the client to process emotions.

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A nurse is preparing to obtain the oxygen saturation of a client who has peripheral edema and thickened toenails. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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