Which of the following sites is best suited for measuring oxygen saturation (pulse oximetry)?
1. A polished ring finger of a client with pneumonia whose nail capillary refill time is 2.5 seconds
2. A pierced earlobe of a client with a closed head injury whose nail capillary refill time is 3.5 seconds
3. The ring finger of a client with Parkinson's disease that has a capillary refill time of less than 3 seconds
4. An earlobe of a client who is experiencing moderate diaphoresis with a nail capil-lary refill time of 3.5 seconds
ANS: 2
Determine most appropriate client-specific site (e.g., finger, earlobe) for sensor probe placement by measuring capillary refill. If capillary refill is greater than 3 seconds, select an alternate site. Sites should be free of moisture and tremors, and the nail should be free of polish (no artificial nails).
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The nurse would recognize the early signs of hypovolemic shock would include: Standard Text: Select all that apply. 1. Increased work of breathing. 2. Pulse rate of 56. 3. Heart rate 130. 4. Capillary refill time greater than three seconds. 5. Blood pressure 72/42.
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