A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?
Finger
Skin fold
Toe
Earlobe
The Correct Answer is D
A. Applying the pulse oximeter to a finger may not be ideal due to edema, which can affect the accuracy of the reading.
B. Using a skin fold is not a typical location for pulse oximetry and may not provide accurate readings.
C. Applying the probe to a toe may be less effective if the toenails are thickened, potentially affecting blood flow to that area and the accuracy of the reading.
D. The earlobe is a suitable alternative for measuring oxygen saturation, particularly in cases where peripheral sites (like fingers or toes) are compromised.
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Correct Answer is C
Explanation
A. Cloudy urine may indicate sediment or the presence of protein but does not necessarily require immediate notification to the provider.
B. A strong odor in the first-voided urine can be normal or due to dehydration or dietary factors, and does not immediately warrant concern.
C. A urine output of 175 mL in 8 hours is significantly low and indicates possible oliguria, which is a concern for impaired renal function and should be reported to the provider.
D. A urine output of 2,200 mL in 24 hours can indicate normal or excessive output (polyuria), but it is less concerning than oliguria and does not require immediate notification.
Correct Answer is A
Explanation
A. Urinary frequency for several days is an expected outcome after catheter removal, as the bladder may become more sensitive and responsive after having been drained continuously.
B. While temporary urinary retention can occur, it is less common after short-term catheterization, and most clients will start voiding normally within a few hours.
C. Blood-tinged urine may occur occasionally, but it is not a typical expected outcome unless there was trauma or irritation during catheterization.
D. Highly concentrated urine can occur due to dehydration or lack of fluid intake, but it is not a specific expected outcome following catheter removal.