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- 1. Open EndedALERT
- 2. Open Endedsupplies
- 3. Open Endedbeginning steps
- 4. Open EndedSelect an appropriate site for sensor placement, such as the patient's earlobe, the forehead, the bridge of the nose or a finger, and prepare the site, if necessary.
- 5. Open EndedAssess capillary refill. If the capillary refill time is more than 3 seconds, select an alternative site. If the capillary refill is less than 3 seconds, ensure that the site is free of moisture.
- 6. Open EndedPosition the patient comfortably. Instruct him or her to breathe normally. Attach the sensor to the monitoring site. Reassure the patient that the clip-on probe will feel like a clothespin on the finger but will not hurt. Turn on the oximeter by activating the power. Observe the pulse waveform/intensity display, and listen for a beep. Correlate the oximeter pulse rate with the patient's radial pulse. Leave the sensor in place 10 to 30 seconds, or until the oximeter readout reaches a constant value and the pulse display reaches full strength during each cardiac cycle. Read the peripheral oxygen saturation (SpO2) on the digital display. The peripheral oxygen saturation is known as the SpO2. Discuss your findings with the patient.
- 7. Open EndedIf you plan to monitor oxygen saturation continuously:
- 8. Open EndedIf the patient has been prescribed intermittent or spot-checking of SpO2 or when discontinuing continuous monitoring:
- 9. Open Endedfinishing steps
- 10. Open EndedWhich of the following is a risk factor for decreased oxygen saturation level in a patient? A. Chest wall injury B. Restlessness C. Hypotension D. Prescribed bronchodilators
- 11. Open EndedWhat should the nurse teach nursing assistive personnel (NAP) about selecting the appropriate site for measuring a patient's oxygen saturation level? A. "Do not use the fingers if her nails are polished." B. "I've checked her capillary refill, and it's acceptable in both her hands and feet." C. "Please review the patient's previously documented pulse oximetry readings for the site used." D. "Ask the patient to keep her finger motionless while you are monitoring her oxygen saturation."
- 12. Open EndedThe nurse measures a patient's oxygen saturation level as being 83%. What would the nurse do first? A. Reassess the oxygen saturation in a different location. B. Promptly report the assessment data to the charge nurse. C. Encourage the patient to rest quietly in bed for 30 minutes. D. Ask the patient whether he or she is having trouble breathing.
- 13. Open EndedThe nurse is preparing to measure the oxygen saturation level of a patient with obesity. Which action would help ensure an adequate measurement? A. Place the sensor on the ear. B. Place the sensor on the bridge of the nose. C. Place the sensor on a finger. D. Use a disposable tape-on sensor.
- 14. Open EndedA patient is prescribed continuous oxygen saturation monitoring. The nurse would confirm that the alarms have been set to which limits? A. Low of 85% and high of 100% B. Low of 80% and high of 100% C. Low of 75% and high of 90% D. Low of 82% and high of 95%
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