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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Clients with severe obstructive sleep apnea (OSA) are at high risk of respiratory depression when given opioid analgesics, which can further suppress breathing. The most important intervention is to apply the client’s PAP device (e.g., CPAP or BiPAP) to maintain an open airway and prevent apnea episodes.

Choice B rationale

Lifting and locking the side rails in place ensures the safety of the client but does not directly address the client’s OSA or the potential respiratory depression associated with opioid analgesic administration.

Choice C rationale

Dentures generally do not obstruct breathing unless improperly fitted. The main issue in OSA is airway collapse, which a PAP device directly addresses.

Choice D rationale

Removing dentures or other oral appliances may be necessary for client comfort and safety, but it is not directly related to managing OSA or preventing respiratory compromise associated with opioid analgesic administration.

A. Eschar and slough in the wound. B. Erythema and serosanguineous exudate. C. Well approximated incision site. D. Beefy red granulation tissue. E. Beefy red granulation tissue.

Correct Answer is C

Explanation

Choice A rationale

Eschar and slough are indicative of necrotic tissue and are not signs of proper healing. Eschar is a dry, dark scab or falling away of dead skin, typically caused by a burn, or by the bite of a mite or other insect. Slough is a layer or mass of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation. Both eschar and slough need to be removed for proper wound healing to occur.

Choice B rationale

Erythema and serosanguineous exudate can be present in the early stages of wound healing, but one week post-surgery, these signs may indicate inflammation or infection rather than

proper healing. Erythema is redness of the skin caused by increased blood flow to the capillaries, often a sign of infection or irritation. Serosanguineous exudate is a thin, watery fluid that is slightly pink due to the presence of small amounts of blood, which can be normal immediately after surgery but should decrease over time.

Choice C rationale

A well-approximated incision site is a sign of proper healing. This means that the edges of the wound are close together and aligned, which promotes faster and more efficient healing.

Proper approximation of the wound edges reduces the risk of infection and promotes the formation of a strong, healthy scar.

Choice D rationale

Beefy red granulation tissue is a sign of healing in open wounds, not in surgical incisions that are closed. Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. It is typically bright red or pink and indicates that the wound is healing from the inside out. However, in a surgical incision that is healing properly, the wound edges should be well approximated, and granulation tissue should not be visible.

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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 nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

Correct Answer is A

Explanation

The nurse is caring for a client one week post-surgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

Correct Answer is C

Explanation

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