A patient is being monitored with pulse oximetry. Which of the following does the nurse know will influence the values?
a. Placement of the sensor on the arm
b. Patient's diagnosis of peripheral vascular disease
c. Reduced amount of light in the room
d. Increased temperature of the room
B
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A The sensor should be placed on an extremity site (such as an earlobe or digit) with adequate local circulation, and the site should be free of moisture. The sensor should not be positioned on the arm.
B Peripheral vascular disease can reduce pulse volume, which may affect the pulse oximetry reading.
C Reduced light in the room will not affect the oximetry reading. Outside light sources can interfere with the oximeter's ability to process reflected light.
D An increased temperature of the room will not affect the oximetry reading. If the room were very cold, the patient's peripheral blood flow might decrease, affecting the oximetry reading.
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A nurse is developing a plan of care for a preterm infant experiencing respiratory distress. Which of the following would the nurse be least likely to include in this plan?
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The nurse is assessing extraocular eye movements (EOMs) in an older adult client and finds that the client is unable to sustain an upward gaze for longer than 2 seconds. What does the nurse do next?
a. Repeat the test while holding the client's head in a fixed position. b. Perform a cover-uncover eye test. c. Document the finding and continue as-sessing. d. Assess for additional signs of impending brain attack.
The patient has a history of interstitial lung disease. Which assessment finding in today's examination would the nurse attribute to a different pathology?
1. New-onset chest pain 2. Increasing shortness of breath 3. Clubbing of the fingers 4. Hemoptysis