A patient has a pulse oximeter reading of 91% on a finger with dark nail polish. The patient is alert and breathing comfortably. Which action should the nurse take first?
Correct answer: C. Warm the hand and repeat the reading on a suitable site
- A. Document the reading as severe hypoxaemia
- B. Remove the sensor and stop monitoring the patient
- C. Warm the hand and repeat the reading on a suitable site
- D. Administer a sedative to reduce possible anxiety
Explanation
Nail polish and poor peripheral perfusion can interfere with pulse oximeter accuracy. The nurse should improve the measurement conditions and repeat the reading before interpreting an unexpected value in a comfortable patient.
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About Vital Signs and Monitoring
Vital signs include temperature, pulse, respiration, blood pressure, oxygen saturation and pain assessment. Coverage includes correct measurement sites and techniques, normal adult ranges, factors that alter readings, trends in patient observations, and the difference between an abnormal finding that needs reassessment and one requiring immediate reporting.
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