The nurse is planning to obtain the pulse oximeter reading of a patient.
What action by the nurse is correct?

Place the probe on a finger that has slow or delayed capillary refill.

Plan to document the pulse oximeter reading as a percent.

Assure the reading is taken in bright light, such as sunlight or fluorescent light.

Avoid removing dark nail polish before the reading is obtained.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Placing the pulse oximeter probe on a finger with slow or delayed capillary refill can lead to inaccurate readings. Slow capillary refill indicates poor peripheral perfusion, which may affect the accuracy of pulse oximetry readings. The nurse should select a finger with normal capillary refill to obtain accurate readings.

Choice B rationale:

Documenting the pulse oximeter reading as a percent is the correct action. Pulse oximeter readings are expressed as percentages, representing the oxygen saturation level in the patient's blood. Normal oxygen saturation levels typically range from 95% to 100%. Documenting the reading in percent allows healthcare providers to monitor the patient's oxygenation status accurately.

Choice C rationale:

Assuring that the reading is taken in bright light, such as sunlight or fluorescent light, is incorrect. Bright light can interfere with the accuracy of pulse oximetry readings by causing the sensor to misinterpret external light as a pulsatile signal. To obtain accurate readings, the pulse oximeter should be used in a well-lit environment but away from direct bright light sources.

Choice D rationale:

Avoiding the removal of dark nail polish before obtaining the reading is incorrect. Dark nail polish can interfere with the pulse oximeter's ability to detect the pulsatile signal from the patient's finger, leading to inaccurate oxygen saturation readings. The nurse should advise the patient to remove dark nail polish or choose another finger without nail polish for the measurement.

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Correct Answer is C

Explanation

Choice A rationale:

Extension refers to the straightening of a joint and is the opposite of flexion. It is not the correct term for the described hand movement.

Choice B rationale:

Abduction is the movement of a body part away from the midline of the body. It does not describe the specific movement of the patient's hand toward the inner aspect of the forearm.

Choice C rationale:

Flexion is the bending of a joint, decreasing the angle between two body parts. When the nurse moves the patient's hand toward the inner aspect of the forearm, it is a flexion movement of the wrist.

Choice D rationale:

Adduction is the movement of a body part toward the midline of the body. It is not the correct term for the described hand movement.

A. The nurse verifies the recipient's fax number before faxing private patient information. B. The nurse documents the patient assessment using objective data. C. The nurse posts the obituary of a patient on social media. D. The nurse discards copies of patient information into the regular trash bin. E. The nurse accesses the nurse's own health record via computer.

Correct Answer is ["C","D"]

Explanation

Choice A rationale:

The nurse verifies the recipient's fax number before faxing private patient information. This action is appropriate and ensures that patient information is sent to the correct recipient, maintaining patient confidentiality and privacy. Verifying recipient information is a standard practice in healthcare settings to prevent data breaches.

Choice B rationale:

The nurse documents the patient assessment using objective data. This action is appropriate and follows evidence-based practice guidelines. Objective data are measurable and observable, providing a clear picture of the patient's condition. Objective documentation enhances communication among healthcare providers and ensures accurate representation of the patient's status.

Choice C rationale:

The nurse posts the obituary of a patient on social media. This action is highly inappropriate and unethical. It breaches patient confidentiality and privacy, violating the Health Insurance Portability and Accountability Act (HIPAA) regulations. Sharing patient information, especially sensitive details like an obituary, on social media platforms is a serious violation of privacy and can lead to legal consequences.

Choice D rationale:

The nurse discards copies of patient information into the regular trash bin. This action is inappropriate and violates patient confidentiality. Proper disposal of patient information is crucial to protect patient privacy and comply with regulations. Patient documents should be shredded or disposed of in designated secure bins to prevent unauthorized access to sensitive information.

Choice E rationale:

The nurse accesses the nurse's own health record via computer. This action is inappropriate unless there is a legitimate reason related to patient care. Accessing one's own health record without a valid purpose is a breach of patient privacy and can lead to disciplinary actions. Healthcare professionals should only access patient records when necessary for providing care and treatment.

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The nurse is planning to obtain the pulse oximeter reading of a patient.What action by the nurse is correct?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is ["C","D"]

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The nurse is planning to obtain the pulse oximeter reading of a patient.
What action by the nurse is correct?