Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching?
A. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds.
Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds: Capillary refill time is not directly related to the placement of the pulse oximetry probe.Capillary refill is assessed to evaluate peripheral perfusion.
B. Use an adhesive oximetry probe for a client who has a latex allergy.
Use an adhesive oximetry probe for a client who has a latex allergy: The type of probe used for pulse oximetry is important, especially for clients with latex allergies. However, the correct action is to use a nonlatex probe or a probe that is compatible with the client's allergy, not necessarily an adhesive probe.
C. Remove polish from the client's fingernail before applying the oximetry probe.
Remove polish from the client's fingernail before applying the oximetry probe: Correct. Nail polish can interfere with the accuracy of pulse oximetry readings, as it may affect light transmission through the nail bed. It is essential to remove nail polish or artificial nails before applying the probe.
D. Lubricate the tip of the oximetry probe.
Lubricate the tip of the oximetry probe: Lubricating the tip of the oximetry probe is not necessary for proper use and may interfere with the accuracy of readings.
This question is an excerpt from Nurse Dive's nursing test bank - LPN ATI fundamental proctored exam. Take the full exam now
Full Explanation
A. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds: Capillary refill time is not directly related to the placement of the pulse oximetry probe.
Capillary refill is assessed to evaluate peripheral perfusion.
B. Use an adhesive oximetry probe for a client who has a latex allergy: The type of probe used for pulse oximetry is important, especially for clients with latex allergies. However, the correct action is to use a nonlatex probe or a probe that is compatible with the client's allergy, not necessarily an adhesive probe.
C. Remove polish from the client's fingernail before applying the oximetry probe: Correct. Nail polish can interfere with the accuracy of pulse oximetry readings, as it may affect light transmission through the nail bed. It is essential to remove nail polish or artificial nails before applying the probe.
D. Lubricate the tip of the oximetry probe: Lubricating the tip of the oximetry probe is not necessary for proper use and may interfere with the accuracy of readings.
Similar Questions
A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider?
A. Heart rate 62/min
Heart rate 62/min: A heart rate of 62 beats per minute is within the normal range for many adults and may not require immediate reporting unless it is a significant change from the client's baseline.
B. Urine output of 200 mL per 8 hr
Urine output of 200 mL per 8 hr: Correct. A urine output of 200 mL in 8 hours is considered low and may indicate inadequate kidney perfusion or function. It should be reported to the provider as it could be a sign of renal impairment or dehydration.
C. Pulse oximetry 95% on room air
Pulse oximetry 95% on room air: A pulse oximetry reading of 95% on room air is within the normal range for oxygen saturation in most healthy individuals. It does not require immediate reporting unless the client has a specific condition or baseline that warrants concern.
D. BP 112/76 mm Hg
BP 112/76 mm Hg: Blood pressure of 112/76 mm Hg is within the normal range for many adults and may not require immediate reporting unless there are specific concerns related to the client's medical history or condition.
Full Explanation
A. Heart rate 62/min: A heart rate of 62 beats per minute is within the normal range for many adults and may not require immediate reporting unless it is a significant change from the client's baseline.
B. Urine output of 200 mL per 8 hr: Correct. A urine output of 200 mL in 8 hours is considered low and may indicate inadequate kidney perfusion or function. It should be reported to the provider as it could be a sign of renal impairment or dehydration.
C. Pulse oximetry 95% on room air: A pulse oximetry reading of 95% on room air is within the normal range for oxygen saturation in most healthy individuals. It does not require immediate reporting unless the client has a specific condition or baseline that warrants concern.
D. BP 112/76 mm Hg: Blood pressure of 112/76 mm Hg is within the normal range for many adults and may not require immediate reporting unless there are specific concerns related to the client's medical history or condition.
A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles?
A. Confidentiality
Confidentiality: Confidentiality refers to the duty to respect and protect the client's private information and not disclose it without the client's consent or appropriate legal authorization.
B. Nonmaleficence
Nonmaleficence: Nonmaleficence means "do no harm." It is the ethical principle that requires healthcare professionals to avoid causing harm to their clients and to balance potential benefits with possible risks.
C. Accountability
Accountability: Accountability is the ethical principle that refers to the responsibility of healthcare professionals to answer for their actions and decisions in providing care to clients.
D. Autonomy
Autonomy: Correct. Autonomy is the ethical principle that respects a person's right to make their own decisions and about their healthcare. Allowing a client to make decisions about their treatment plan is an example of promoting autonomy and respecting their right toselfdetermination.
Full Explanation
A. Confidentiality: Confidentiality refers to the duty to respect and protect the client's private information and not disclose it without the client's consent or appropriate legal authorization.
B. Nonmaleficence: Nonmaleficence means "do no harm." It is the ethical principle that requires healthcare professionals to avoid causing harm to their clients and to balance potential benefits with possible risks.
C. Accountability: Accountability is the ethical principle that refers to the responsibility of healthcare professionals to answer for their actions and decisions in providing care to clients.
D. Autonomy: Correct. Autonomy is the ethical principle that respects a person's right to make their own decisions and about their healthcare. Allowing a client to make decisions about their treatment plan is an example of promoting autonomy and respecting their right to
selfdetermination.
A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take?
A. Restrict the client's visitors to the immediate family.
Restrict the client's visitors to the immediate family: While tuberculosis is a communicable disease, restricting visitors to the immediate family is not a standard precautionary measure. Visitors should be educated about infection control measures and individuals with active tuberculosismay need to wear masks in certain situations.
B. Assign the client to a negative pressure airflow room.
Assign the client to a negative pressure airflow room: Correct. Clients with active tuberculosis should be placed in a negative pressure airflow room to prevent the spread of infectious airborne particles to other areas of the facility. Negative pressure ensures that air from the room does not flow to other parts of the facility.
C. Discard personal protective equipment outside the client's room.
Discard personal protective equipment outside the client's room: Personal protective equipment (PPE) should be removed and discarded according to facility policy, which often includes removing PPE inside the client's room and properly disposing of it afterward. The nurse should follow standard precautions for infection control.
D. Have the client wear a HEPA mask during transportation throughout the facility.
Have the client wear a HEPA mask during transportation throughout the facility: While wearing a HEPA mask may be necessary for clients with tuberculosis, it is not related to the initial admission process. Clients with active tuberculosis may be asked to wear a HEPA mask during transportation when they need to leave their negative pressure room.
Full Explanation
A. Restrict the client's visitors to the immediate family: While tuberculosis is a communicable disease, restricting visitors to the immediate family is not a standard precautionary measure. Visitors should be educated about infection control measures and individuals with active tuberculosis
may need to wear masks in certain situations.
B. Assign the client to a negative pressure airflow room: Correct. Clients with active tuberculosis should be placed in a negative pressure airflow room to prevent the spread of infectious airborne particles to other areas of the facility. Negative pressure ensures that air from the room does not flow to other parts of the facility.
C. Discard personal protective equipment outside the client's room: Personal protective equipment (PPE) should be removed and discarded according to facility policy, which often includes removing PPE inside the client's room and properly disposing of it afterward. The nurse should follow standard precautions for infection control.
D. Have the client wear a HEPA mask during transportation throughout the facility: While wearing a HEPA mask may be necessary for clients with tuberculosis, it is not related to the initial admission process. Clients with active tuberculosis may be asked to wear a HEPA mask during transportation when they need to leave their negative pressure room.