4.3: Test Yourself- Answers

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Page ID: 16850

Lapum et al.
Ryerson University (Daphne Cockwell School of Nursing) via Ryerson University Library

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1. Match each person with the estimated SpO2.

Healthy adolescent——————97% SpO2

Adult with lung disease————-92% SpO2

80-year-old adult——————–95% SpO2

2. A client’s oxygen saturation is measured via pulse oximetry using a finger probe. The radial pulse does not coincide with the pulse displayed on the oximeter. How should the healthcare provider respond?

a. Notify the most responsible provider

b. Document the findings in the client’s chart

c. Assume the client has hypoxic tissue injury

d. Repeat the measurements using an earlobe probe **

Rationale: The correct answer is d (repeat the measurements using an earlobe probe). Repeat the measurements using an ear probe. The O2 saturation reading is inaccurate when the palpable pulse does not coincide with the pulse displayed on the pulse oximeter. This could be caused by conditions related to poor circulation and/or peripheral vasoconstriction. The best action is to use an alternate method to obtain the O2 saturation such as an earlobe probe.

3. The physician asks for an oxygen saturation report on a client who has peripheral limb tremors. What is the best location to place the probe?

a. Ear **

b. Toe

c. Finger

d. Thumb

Rationale: The correct answer is a (ear). Tremors can affect the ability of the pulse oximeter to accurately read the pulsations and oxygen saturations. The toe, finger, and thumb are all affected by the tremors. Therefore, it is best to use the earlobe to measure O2 saturation.

4. A person’s oxygen saturation is 89% and the pulse displayed on the pulse oximeter is aligned with the radial pulse. How should the healthcare provider respond?

a. Give oxygen to the client

b. Raise up the head of the client’s bed

c. Ask the client, “are you having any difficulty breathing?” **

d. Note this finding as normal and continue with assessment

Rationale: The correct answer is c (ask the client, “are you having any difficulty breathing?”). Ask the client if he/she is having any difficulty breathing. This oxygen saturation is considered abnormal. Further assessments need to be completed prior to an intervention. The first assessment starts with the respiratory system including a subjective assessment of the client’s breathing and whether he/she is having difficulty breathing. The context of the client’s current health state will determine how you proceed with interventions.