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 {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

i. Clean the puncture site with antiseptic and allow it to dry helps reduce the risk of infection and ensures an accurate reading by preventing contamination.

ii. Wipe away the first drop of blood before collecting the sample is the best next step because the first drop may contain tissue fluid, which can affect glucose accuracy.

Incorrect answers:

Warming the client's hand before performing the fingerstick improves blood flow, making it easier to obtain an adequate sample, especially in clients with diabetes who may have impaired circulation.

Massage the finger gently from the base toward the tip before puncturing promotes blood flow but should be done carefully to avoid excess squeezing, which can lead to inaccurate results.

Ensure the client's hand is below heart level when obtaining the sample encourages blood flow, making collection easier.

Apply firm pressure to the site after obtaining the sample prevents excessive bleeding and helps close the puncture site.

A. Place the client on their side with their head forward. B. Administer an anticonvulsant medication. C. Time the length of the client's seizure. D. Loosen the client's gown and allow them to move freely.

Correct Answer is A

Explanation

A. Place the client on their side with their head forward. This position helps maintain an open airway, prevents aspiration, and allows secretions to drain. It is the priority intervention during an active seizure.

B. Administer an anticonvulsant medication. Medications like benzodiazepines (e.g., lorazepam) are used to stop prolonged seizures but are not the immediate priority over airway protection.

C. Time the length of the client's seizure. While monitoring seizure duration is important, ensuring airway protection and safety comes first.

D. Loosen the client's gown and allow them to move freely. While restrictive clothing should be loosened, allowing unrestricted movement could lead to self-injury.

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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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Explanation

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