The nurse is obtaining an oxygen saturation reading from a female patient who was brought in after collapsing at a party. Factors that may lead to inaccurate SpO2 readings include which of the following? (Select all that apply.)
a. Using a pulsatile area to attach the probe
b. The patient wearing fingernail polish
c. Measuring the level intermittently
d. The patient being anemic
e. Measuring the level continuously
B, D
A vascular, pulsatile area (e.g., fingertip or earlobe) is needed to detect the degree of change in the transmitted light. Factors that affect light transmission (e.g., sensor movement, fingernail polish) or peripheral arterial pulsations (e.g., hypotension, anemia) also affect the measurement of SpO2 . An awareness of these factors allows for accurate interpretation of abnormal SpO2 measurements. Measuring SpO2 can be conducted intermittently or continuously to assess ongoing therapies.
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Which of the following could the nurse perform in order to reduce the anxiety of a 70-year-old client about to undergo a physical examination?
1. Ask the client to identify herself. 2. Give the client a gown to wear. 3. Tell the client what will be done throughout the examination. 4. Tells the client that there is no need to be nervous.
The nurse is evaluating outcomes about a family's ability to care for an adolescent child that is recovering from a spinal cord injury. Which statements indicate that this family is transitioning in a healthy manner?
A) The patient states the injuries "messed up" the rest of his life. B) The mother states the need to have a break at least once per week. C) The patient states fewer episodes of nausea with changing position. D) The father states the child's accident has brought the family closer together. E) The mother states the ability to provide care for the child is becoming easier.
Patients should be warned about the overuse of topical wintergreen oil to treat muscle strains, as overapplication can lead to:
1. Respiratory depression 2. Cardiac disturbance 3. Salicylates poisoning 4. Life-threatening rashes
The nurse must perform a procedure on a toddler. The technique most appropriate when performing the procedure is to
1. ask the mother to restrain the childduring the procedure. 2. ask the child if it is okay to start theprocedure. 3. perform the procedure in the child'shospital bed. 4. allow the child to cry or scream.