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?
Capillary refill time is 2 seconds.
2+ edema of fingers and hands.
Radial pulse volume is 3+.
Blood pressure is 142/88 mm Hg.
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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Correct Answer is B
Explanation
Choice A rationale
Testing for a gag reflex before performing oral care is a standard practice to ensure the client’s safety and prevent aspiration. This action does not indicate a need for additional training.
Choice B rationale
Placing the client in a supine position is incorrect and indicates a need for additional training. The correct position for performing oral care on an unconscious client is a side-lying position to prevent aspiration and ensure secretions can drain from the mouth.
Choice C rationale
Suctioning secretions from the posterior pharynx is a necessary action to maintain airway patency and prevent aspiration. This action does not indicate a need for additional training.
Choice D rationale
Using an oral airway to keep the teeth apart is a standard practice to facilitate oral care and prevent the client from biting down on the caregiver’s fingers or equipment. This action does not indicate a need for additional training.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Monitoring the client’s white blood cell count is essential to assess the presence and severity of infection. An elevated white blood cell count can indicate an ongoing infection, including MRSA.
Choice B rationale
Sending wound drainage for culture and sensitivity is crucial to identify the specific bacteria causing the infection and to determine the most effective antibiotics for treatment.
Choice C rationale
Instituting contact precautions for staff and visitors is necessary to prevent the spread of MRSA. This includes wearing gloves and gowns when entering the client’s room and ensuring proper hand hygiene.
Choice D rationale
Explaining the purpose of a low bacteria diet is not relevant to the management of MRSA infections. MRSA management focuses on infection control measures and appropriate antibiotic therapy.
Choice E rationale
Using standard precautions and wearing a mask is not specific to MRSA management. While standard precautions are always important, contact precautions are more relevant for preventing the spread of MRSA.