A nurse is reinforcing discharge teaching with the parents of an infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?
The pulse oximeter might not be accurate during times of excessive movement.
We will notify the doctor if the pulse oximeter consistently reads 100%.
The probe of the pulse oximeter can be applied to a finger or a toe.
We will rotate the probe of the pulse oximeter every 24 hours.
The Correct Answer is B
Choice A reason: The pulse oximeter might not be accurate during times of excessive movement is a correct statement, as movement can interfere with the detection of the pulse and the oxygen saturation. The parents should try to keep the infant still and calm while using the pulse oximeter.
Choice B reason: We will notify the doctor if the pulse oximeter consistently reads 100% is an incorrect statement, as it indicates a misunderstanding of the normal range of oxygen saturation. The parents should not be alarmed if the pulse oximeter reads 100%, as it means that the infant's blood is fully saturated with oxygen. The normal range of oxygen saturation for infants is 95% to 100%.
Choice C reason: The probe of the pulse oximeter can be applied to a finger or a toe is a correct statement, as these are suitable sites for measuring the oxygen saturation in infants. The parents should make sure that the probe fits snugly and securely on the infant's finger or toe.
Choice D reason: We will rotate the probe of the pulse oximeter every 24 hours is a correct statement, as it helps to prevent skin irritation, pressure ulcers, or infection from prolonged contact with the probe. The parents should also check the infant's skin regularly for any signs of redness, swelling, or pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Encourages oral fluid intake during waking hours is not an action that the nurse should intervene. Encouraging oral fluid intake during waking hours is a part of a bladder-training program, as it helps to maintain adequate hydration and prevent urinary tract infections. The nurse should instruct the AP to limit the client's fluid intake before bedtime, as it may cause nocturia and disrupt the bladder-training schedule.
Choice B reason: Assists the client to the bathroom every 2 hr is not an action that the nurse should intervene. Assisting the client to the bathroom every 2 hr is a part of a bladder-training program, as it helps to establish a regular pattern of voiding and reduce the risk of incontinence. The nurse should instruct the AP to gradually increase the interval between bathroom visits, as the client's bladder capacity and control improve.
Choice C reason: Offers the opportunity to urinate 15 min prior to bathing is not an action that the nurse should intervene. Offering the opportunity to urinate 15 min prior to bathing is a part of a bladder-training program, as it helps to prevent the stimulation of the micturition reflex by warm water and reduce the risk of accidental voiding. The nurse should instruct the AP to avoid giving the client diuretics, caffeine, or alcohol, as they may increase the urine output and frequency.
Choice D reason: Instructs the client to urinate whenever the urge occurs is an action that the nurse should intervene. Instructing the client to urinate whenever the urge occurs is not a part of a bladder-training program, as it does not help to improve the bladder function and may worsen the urge incontinence. The nurse should instruct the AP to teach the client some techniques to suppress the urge, such as pelvic floor exercises, deep breathing, or distraction.
Correct Answer is D
Explanation
Choice A reason: Bacteria are not detected by the stool guaiac test. The stool guaiac test is a chemical test that reacts with hemoglobin, a protein found in red blood cells. Bacteria are microorganisms that do not contain hemoglobin.
Choice B reason: Fat is not detected by the stool guaiac test. The stool guaiac test is a chemical test that reacts with hemoglobin, a protein found in red blood cells. Fat is a lipid that does not contain hemoglobin.
Choice C reason: Parasites are not detected by the stool guaiac test. The stool guaiac test is a chemical test that reacts with hemoglobin, a protein found in red blood cells. Parasites are organisms that live in or on another host and do not contain hemoglobin.
Choice D reason: Blood is detected by the stool guaiac test. The stool guaiac test is a chemical test that reacts with hemoglobin, a protein found in red blood cells. Blood can indicate bleeding in the gastrointestinal tract, which can be caused by various conditions such as ulcers, polyps, or cancer.
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