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The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

A.

Capillary refill time is 2 seconds.

B.

2+ edema of fingers and hands.

C.

Radial pulse volume is 3+.

D.

Blood pressure is 142/88 mm Hg.

Answer and Explanation

The Correct Answer is B

Choice A rationale

 

Capillary refill time is 2 seconds. A capillary refill time of 2 seconds is within normal limits and is unlikely to affect the accuracy of the pulse oximetry reading.

 

Choice B rationale

 

2+ edema of fingers and hands. Edema can interfere with the accuracy of pulse oximetry readings by affecting the perfusion of the area where the sensor is placed. This can lead to falsely low oxygen saturation readings.

 

Choice C rationale

 

Radial pulse volume is 3+. A strong radial pulse indicates good peripheral perfusion, which should not negatively impact the accuracy of the pulse oximetry reading.

 

Choice D rationale

 

Blood pressure is 142/88 mm Hg. While elevated blood pressure can have various effects on the body, it is not likely to directly affect the accuracy of a pulse oximetry reading.


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View Related questions

Correct Answer is C

Explanation

Choice A rationale

Advising the UAP to wear a standard face mask to obtain vital signs and then get fitted for a filter mask before providing personal care is not appropriate. The UAP should be properly equipped with the correct protective gear before any contact with the client.

Choice B rationale

Instructing the UAP that a standard face mask is sufficient to provide care for the assigned client is incorrect. Bacterial meningitis requires droplet precautions, and a standard face mask is sufficient for this type of precaution, not a particulate filter mask.

Choice C rationale

Sending the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client is unnecessary because bacterial meningitis requires droplet precautions, which only necessitate a standard surgical mask, not a particulate filter mask like an N953.

Choice D rationale

Before changing assignments, determining which staff members have fitted particulate filter masks is prudent but not necessary for caring for a client with bacterial meningitis under droplet precautions. The focus should be on ensuring the UAP understands that a standard mask is sufficient.

Correct Answer is A

Explanation

Choice A rationale

Verifying the placement of the pulse oximeter is the first step to ensure the accuracy of the oxygen saturation reading. An incorrect placement can lead to inaccurate readings, and addressing this issue can help determine if further interventions are needed.

Choice B rationale

Increasing the oxygen to 3 L/minute may be necessary if the oxygen saturation remains low after verifying the pulse oximeter placement. However, this should be done after ensuring the accuracy of the initial reading.

Choice C rationale

Switching to a non-rebreather mask is not the immediate action to take. Non-rebreather masks deliver a high concentration of oxygen, typically reserved for severe hypoxia. The patient’s oxygen saturation is low, but not critically low.

Choice D rationale

Removing the nasal cannula is not appropriate as it would further decrease the oxygen supply to the patient. The goal is to improve oxygenation, not reduce it.

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