Author Question: Which of the following sites is best suited for measuring oxygen saturation (pulse oximetry)? 1. ... (Read 121 times)

storky111 · **on:** Jul 23, 2018

Which of the following sites is best suited for measuring oxygen saturation (pulse oximetry)?

1. A polished ring finger of a client with pneumonia whose nail capillary refill time is 2.5 seconds
2. A pierced earlobe of a client with a closed head injury whose nail capillary refill time is 3.5 seconds
3. The ring finger of a client with Parkinson's disease that has a capillary refill time of less than 3 seconds
4. An earlobe of a client who is experiencing moderate diaphoresis with a nail capil-lary refill time of 3.5 seconds

Question 2

The nurse recognizes that which of the following clients present at the annual July 4th marathon is at greatest risk for hyperthermia and the resulting heatstroke?

1. A 34-year-old running for the first time in the July 4th marathon who is sweating profusely
2. A 16-year-old volunteer, with type 1, insulin-dependent diabetes, who is checking runners in for the marathon at the starting gate
3. A 75-year-old who is prescribed medication for Crohn's disease and who is sit-ting outdoors watching her granddaughter run the marathon
4. A 55-year-old diagnosed with bipolar disease and prescribed a phenothiazine (Serentil), who will be walking the marathon course

zacnyjessica · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 2
Determine most appropriate client-specific site (e.g., finger, earlobe) for sensor probe placement by measuring capillary refill. If capillary refill is greater than 3 seconds, select an alternate site. Sites should be free of moisture and tremors, and the nail should be free of polish (no artificial nails).

Answer to Question 2

ANS: 2
Clients at risk include those who are very young or very old and those who have cardiovascular disease, hypothyroidism, diabetes, or alcoholism. Also at risk are those who take medications that decrease the body's ability to lose heat (e.g., phenothiazines, anticholinergics, diuretics, am-phetamines, and beta-adrenergic receptor antagonists) and those who exercise or work strenu-ously (e.g., athletes, construction workers, and farmers). While all the options represent risk fac-tors, the degree of exercise, medical history, and age are greatest for the 16-year-old client with diabetes.