The nurse is assessing the client's pulse oximetry. The measurement is below the expected reference range. Which of the following actions should the nurse take? (Select all that apply)
- Ensure the client's nails are clean and dry.
- Request the client to hold their breath for 15 seconds prior to measuring pulse oximetry.
- Move the pulse oximeter probe to the client's opposite hand.
- Warm the client's hand prior to measuring pulse oximetry.
- Ensure client's capillary refill is greater than 2 seconds prior to placing probe.
Answer (2)
To address low pulse oximetry readings, a nurse should ensure the client's nails are clean and dry, warm the client's hand before measuring, and consider moving the probe to the opposite hand for better circulation. Avoid asking the client to hold their breath and check capillary refill time as those actions might not improve the accuracy of the oximeter. These actions will help in obtaining reliable oxygen saturation readings.
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When a nurse finds that a client's pulse oximetry is below the expected reference range, it is essential to take appropriate steps to ensure an accurate reading and address potential causes for the low measurement. Here are suitable actions for a nurse in this situation:
Ensure the client's nails are clean and dry : This is important because dirt, oils, or moisture on the nails could interfere with the sensor's ability to accurately detect blood oxygen levels.
Move the pulse oximeter probe to the client's opposite hand : If there is any suspicion that the position or the circulation in one finger is affecting the reading, relocating the probe to a different finger can provide a more reliable measurement.
Warm the client's hand prior to measuring pulse oximetry : Cold extremities can lead to poor peripheral blood flow, which may result in inaccurate readings. Warming the client's hand can improve circulation and provide a better environment for an accurate assessment.
To note, the following actions from the list provided are generally not recommended:
Request the client to hold their breath for 15 seconds prior to measuring pulse oximetry : Holding the breath can actually decrease oxygen levels and is not a standard practice to improve pulse oximetry readings.
Ensure client's capillary refill is greater than 2 seconds prior to placing probe : A capillary refill time greater than 2 seconds may indicate poor perfusion, which might lead to an inaccurate reading; instead, you would want capillary refill to be 2 seconds or less for better accuracy of the pulse oximetry.
Overall, the goal is to ensure proper probe placement, optimal finger conditions, and adequate circulation to achieve the most accurate measurement possible.
