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?
Capillary refill time is 2 seconds.
2+ edema of fingers and hands.
Radial pulse volume is 3+.
Blood pressure is 142/88 mm Hg.
The Correct Answer is B
Choice B rationale
2+ edema of fingers and hands. Edema can interfere with the accuracy of pulse oximetry readings by affecting the perfusion of the area where the sensor is placed. This can lead to falsely low oxygen saturation readings.
Choice A rationale
Capillary refill time is 2 seconds. A capillary refill time of 2 seconds is within normal limits and is unlikely to affect the accuracy of the pulse oximetry reading.
Choice C rationale
Radial pulse volume is 3+. A strong radial pulse indicates good peripheral perfusion, which should not negatively impact the accuracy of the pulse oximetry reading.
Choice D rationale
Blood pressure is 142/88 mm Hg. While elevated blood pressure can have various effects on the body, it is not likely to directly affect the accuracy of a pulse oximetry reading.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
The correct answer is: Type of Exercises: Isometric exercises Isotonic exercises Actions to Take: Support the extremity Encourage active range of motion exercises Parameters to Monitor: Pain level Range of motion Rationale:
Isometric exercises: These exercises involve contracting the muscle without moving the joint. They are beneficial for maintaining muscle strength and preventing muscle atrophy, especially when the client is unable to perform full range of motion exercises due to pain or limited mobility. Isotonic exercises: These exercises involve moving the joint through its full range of motion with muscle contraction. They help improve muscle strength, endurance, and joint mobility. Isotonic exercises are important for clients who are progressing in their recovery and are able to tolerate more movement. Support the extremity: Providing support to the extremity during exercises helps prevent injury and reduces pain. It also ensures that the client performs the exercises correctly and safely. Encourage active range of motion exercises: Active range of motion exercises involve the client moving their own joints through their full range of motion. These exercises help improve joint mobility, muscle strength, and overall function. Encouraging the client to perform these exercises promotes independence and active participation in their recovery. Pain level: Monitoring the client’s pain level is important to ensure that the exercises are not causing excessive discomfort or injury. Pain management is crucial for promoting compliance with the exercise regimen and facilitating recovery. Range of motion: Assessing the client’s range of motion helps determine the effectiveness of the exercises and the progress of the client’s recovery. It also helps identify any limitations or areas that need further attention
Correct Answer is A
Explanation
Choice A rationale
Using the syringe to remove the specimen from the catheter requires the nurse to wear gloves to maintain sterility and prevent contamination. Gloves protect both the nurse and the patient from potential pathogens present in the urine.
Choice B rationale
Transporting the urine specimen to the laboratory does not require gloves as the specimen is already secured in a biohazard bag, minimizing the risk of contamination.
Choice C rationale
Recording the output on the flowsheet in the client’s room does not involve direct contact with the urine specimen, so gloves are not necessary.
Choice D rationale
Clamping the urinary catheter prior to the collection does not require gloves as it is a preliminary step that does not involve direct contact with the urine.
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