The patient was found unresponsive in her apartment and is being brought to the emergency department. She has arm, hand, and leg edema, her temperature is 95.6° F, and her hands are cold secondary to her history of peripheral vascular disease
It is reported that she has a latex allergy. To quickly measure the patient's oxygen saturation, what should the nurse do?
a. Attach a finger probe to the patient's index finger.
b. Place a nonadhesive sensor on the patient's ear lobe.
c. Attach a disposable adhesive sensor to the bridge of the patient's nose.
d. Place the sensor on the same arm that the electronic blood pressure cuff is on.
ANS: B
Select ear or bridge of nose if an adult patient has a history of peripheral vascular disease. Do not attach sensor to finger, ear, or bridge of nose if area is edematous or skin integrity is compromised. Do not use disposable adhesive probes if the patient has latex allergy. Do not attach probe to fingers that are hypothermic. Do not place sensor on the same extremity as electronic blood pressure cuff because blood flow to finger will be temporarily interrupted when cuff inflates.
You might also like to view...
A client demonstrating symptoms of psychosis asks a psychiatric technician " What's the matter
with me?" The technician replies "Your wing nuts need tightening.". Another technician states "Yeah, you're like a six-pack without the plastic holder.". The client looks perplexed and wanders off. The nurse who overheard the exchange will need to take action based on a. violation of the client's right to be treated with dignity and respect. b. the nursing obligation to report caregiver negligence. c. preventing defamation of the client's character. d. supervisory liability.
A nurse is obtaining a drug history from an older adult patient who is taking multiple medications prescribed by different providers. Which two medications taken together create a reason for concern?
a. Acetaminophen [Tylenol] and oxycodone b. Amitriptyline [Elavil] and diphenhydra-mine [Benadryl] c. Fexofenadine [Allegra] and an over-the-counter laxative d. Zolpidem [Ambien] and sertraline [Zoloft]
Nurses, physicians, and social workers finalize the plan of care and coordinate discharge for a homeless person who will need wound care and follow up over the next 4 weeks
Each member contributes based on his or her area of expertise but also recognize other members' strengths. Which of the QSEN competencies are being demonstrated? a. Quality improvement b. Evidence-based practice c. Teamwork and collaboration d. Patient-centered care
Which of these findings would be the most significant when assessing a patient who has multiple traumas as a result of a motor vehicle accident?
1. a respiratory rate of 24 breaths per minute 2. a heart rate of 100 beats per minute 3. hypotension 4. pain in one arm