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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 D

Explanation

Choice A rationale

Wearing gloves to dispose of the needle and syringe is a good practice to prevent needlestick injuries and contamination. However, it does not directly indicate an understanding of standard precautions, which emphasize hand hygiene as a primary measure.

Choice B rationale

Removing the needle before discarding used syringes is not recommended as it increases the risk of needlestick injuries. Standard precautions emphasize the safe disposal of sharps in puncture-resistant containers without manipulating the needle.

Choice C rationale

Donning a face mask before administering medication is not a standard precaution for handling syringes and needles. Standard precautions focus more on hand hygiene and the use of gloves when there is a risk of exposure to blood or body fluids.

Choice D rationale

Washing hands before handling the needle and syringe is a fundamental aspect of standard precautions. Hand hygiene is the most effective way to prevent the transmission of infections and is a clear indication of understanding standard precautions.

Correct Answer is B

Explanation

Choice A rationale

Contraction of the left pupil when light shines in the right eye is a normal consensual pupillary response and does not need to be documented in charting by exception. This finding is within normal limits and does not indicate any deviation from the expected outcome.

Choice B rationale

Basilar lung sounds that are diminished in the left lung should be documented because this finding deviates from the normal lung sounds and indicates a potential issue that needs further investigation. Charting by exception focuses on documenting abnormalities or deviations from the norm.

Choice C rationale

Active bowel sounds in the lower right quadrant are a normal finding and do not need to be documented in charting by exception. This assessment is within normal limits and does not indicate any deviation from the expected outcome.

Choice D rationale

Capillary refill of 2 seconds in the lower right foot is a normal finding and does not need to be documented in charting by exception. This assessment is within normal limits and does not indicate any deviation from the expected outcome.

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