The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Blood pressure is 142/88 mm Hg.

Radial pulse volume is 3+.

2+ edema of fingers and hands.

Capillary refill time is 2 seconds.

Answer and Explanation

The Correct Answer is C

A. Blood pressure is 142/88 mm Hg:

While elevated blood pressure may have implications for cardiovascular health, it is not directly related to oxygen saturation levels measured by a pulse oximeter.

B. Radial pulse volume is 3+:

A strong radial pulse volume suggests adequate peripheral perfusion, which would not typically contribute to a low oxygen saturation reading.

C. 2+ edema of fingers and hands:

Edema of the fingers and hands can impair the transmission of light through tissues, which may interfere with the accuracy of oxygen saturation readings obtained from a pulse oximeter. Edematous tissues may absorb light and lead to falsely low readings.

D. Capillary refill time is 2 seconds:

Normal capillary refill time indicates adequate peripheral circulation, which would not typically contribute to a low oxygen saturation reading.

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Correct Answer is C

Explanation

Correct answer: C

A. Irrigate the nasogastric tube with water:

This option is not the best immediate action when a client is choking after vomiting. While irrigating the nasogastric tube with water may help clear the tube itself, it does not directly address the choking episode or potential airway obstruction. The priority in this situation is to ensure the client's airway is clear and maintain their safety.

B. Perform oropharyngeal suctioning:

While suctioning might be used later to clear the airway of secretions, it's not the first-line intervention when someone is actively choking. Suctioning can stimulate the gag reflex and worsen vomiting..

C. Elevate the head of bed 45 degrees:

The primary concern is preventing aspiration (inhaling vomit) which can lead to serious complications. Elevating the head of the bedhelps keep the head and neck in a position that promotes drainage of fluids and reduces the risk of aspiration.

D. Review the advance directive document:

Reviewing the advance directive document is important for understanding the client's wishes regarding their healthcare decisions, but it is not the appropriate action in the immediate management of a choking episode. Ensuring the client's safety and addressing the choking episode take precedence over reviewing documentation.

A. 1.035. B. 1.015. C. 1.005. D. 1.025. E. 1.025.

Correct Answer is A

Explanation

A. 1.035:

This specific gravity value indicates highly concentrated urine. In the context of a client experiencing vomiting, diarrhea, and difficulty tolerating oral fluids, such a high specific gravity would be indicative of significant dehydration. Dehydration occurs when the body loses more fluid than it takes in, leading to an imbalance in electrolytes and an increase in urine concentration.

B. 1.015:

This specific gravity value falls within the normal reference range for urine specific gravity. In the context of vomiting, diarrhea, and difficulty tolerating oral fluids, a value within the normal range may be less likely. However, it's important to note that initial testing may not reflect the full extent of dehydration, especially if the client's fluid intake has been severely limited over a short period.

C. 1.005:

This specific gravity value is at the lower end of the normal reference range for urine specific gravity. In a client experiencing significant fluid loss through vomiting and diarrhea, the urine may become more concentrated as the body attempts to conserve water. Therefore, a value of 1.005 would be less likely on initial testing in this context.

D. 1.025:

Similar to Option B, this specific gravity value falls within the normal reference range. While it's possible for a dehydrated individual to have a specific gravity within the normal range, a value of 1.025 may be less likely in the context of significant fluid loss through vomiting and diarrhea. However, it's important to consider that dehydration severity and urine concentration can vary among individuals.

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The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

Correct Answer is C

Explanation

The nurse is assessing a client who reports a 3 day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on Initial testing? Reference Range: Urine Specific Gravity [1.005 to 1.03]

Correct Answer is A

Explanation

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