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 B
Explanation
A. Observing the client is inappropriate as they are demonstrating signs of choking and require immediate intervention.
B. Performing the Heimlich maneuver is appropriate as the guest is unable to talk, which indicates a potential airway obstruction that needs to be relieved promptly.
C. Slapping the client on the back may not be effective and could worsen the obstruction, especially since they are grasping their throat.
D. Assisting the client to the floor and beginning mouth-to-mouth resuscitation is not appropriate in this situation, as the priority is to clear the obstruction, not to provide rescue breaths.
Correct Answer is C
Explanation
A. Verifying the client's room number is not a reliable method of identification, as multiple clients can be in the same room or the client may have been moved.
B. Checking the client's name on the MAR is a good practice but should be combined with a direct method of identification for accuracy.
C. Asking the client for their full name and date of birth is the standard practice for confirming identity before administering medications, ensuring that the nurse is addressing the correct individual.
D. Asking a family member to verify the client's identity is not appropriate, as the nurse must confirm the client's identity personally to maintain safety and accountability.