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

Ensuring the bevel of the needle is pointing up is crucial for intradermal injections as it allows the medication to be deposited just below the epidermis, forming a small bleb or wheal.

Choice B rationale

The upper arm is not the preferred site for intradermal injections. The inner forearm and upper back are more commonly used as they allow for better visualization of the reaction.

Choice C rationale

Holding the syringe perpendicular to the skin is incorrect for intradermal injections. The correct angle is 5 to 15 degrees to ensure the medication is deposited in the dermis.

Choice D rationale

Massaging the site gently after injection is not recommended for intradermal injections as it can disperse the medication and affect the test results.

A. Determine client’s subjective measure of pain using a numerical pain scale. B. Implement a 24-hour schedule of routine administration of prescribed analgesic. C. Assist the client to ambulate as much as possible during waking hours. D. Provide comfort measures such as topical warm application and tactile massage. E. Encourage increased fluid intake and measure urinary output every 8 hours.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Determine client’s subjective measure of pain using a numerical pain scale. Assessing the client’s pain using a numerical pain scale allows the nurse to understand the client’s perception of their pain and to monitor changes over time. This is a crucial step in managing chronic pain as it provides a baseline for evaluating the effectiveness of interventions.

Choice B rationale

Implement a 24-hour schedule of routine administration of prescribed analgesic. Chronic pain management often requires a consistent and routine administration of analgesics to maintain a stable level of pain control. This approach helps to prevent the peaks and troughs of pain that can occur with as-needed dosing.

Choice C rationale

Assist the client to ambulate as much as possible during waking hours. While ambulation can be beneficial for some clients, it may not be appropriate for all clients with chronic pain, especially if the pain is severe or if ambulation exacerbates the pain. Therefore, this intervention should be individualized based on the client’s condition.

Choice D rationale

Provide comfort measures such as topical warm application and tactile massage. Non- pharmacological interventions such as warm applications and massage can help to alleviate pain and improve comfort. These measures can be used in conjunction with pharmacological treatments to provide a more comprehensive approach to pain management.

Choice E rationale

Encourage increased fluid intake and measure urinary output every 8 hours. While maintaining adequate hydration is important, this intervention is not directly related to the management of chronic pain. It may be more relevant for clients with other conditions such as renal issues.

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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

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

Correct Answer is A

Explanation

The nurse is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

A nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a violation?

The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?

The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client’s attention on which focus?

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?