While recording oxygen with pulse oximetry of a newly married patient, the nurse should do?

AIIMS Rishikesh & Jodhpur NO - 2017

Nursing Foundation

Medium

Appeared in: AIIMS Rishikesh & Jodhpur NO - 2017

Explanation

Pulse oximeters function by transmitting light through tissue; nail polish, especially dark or opaque types, can obstruct this light path.
This obstruction interferes with the sensor's ability to detect changes in light absorption, leading to falsely low or inaccurate oxygen saturation (SpO₂) readings.
Removing nail polish is a standard and necessary step to ensure the device can function correctly and provide a reliable measurement for clinical assessment.
The cue 'newly married' suggests a higher likelihood of nail polish or henna, prompting the nurse to be vigilant about this specific interference.

Option B: Hand washing cleans the skin of dirt and microorganisms but does not remove nail polish, which is the primary source of interference in this context.
Option C: Similar to hand washing, using a sanitizer will clean the skin surface but will not dissolve or remove nail polish.
Option D: Inserting an IV line is an invasive procedure for administering fluids or medications and has no connection to the non-invasive measurement of oxygen saturation.

Clinical Relevance

Nursing practice connection: Knowing Factors affecting the accuracy of pulse oximetry helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Accurate SpO₂ monitoring is vital for detecting hypoxia and guiding treatment decisions, such as the need for supplemental oxygen. An inaccurate reading can lead to missed diagnoses or unnecessary interventions.
Nurses must be aware of common factors that interfere with pulse oximetry, including nail polish, poor circulation, patient movement, and ambient light.
What if? If the patient has gel polish or acrylic nails that cannot be removed easily, the nurse must use an alternative site for the probe, such as a toe (if circulation is adequate), an earlobe, or the bridge of the nose, to ensure an accurate reading.

How to Approach the Question

First, identify the main subject of the question, which is the correct procedure for using a pulse oximeter.
Next, analyze the specific context provided: a 'newly married patient'. Consider what clinical implications this detail might have. In this case, it's a cue for potential nail polish or henna.
Evaluate each option based on its relevance and importance to obtaining an accurate pulse oximetry reading.
Recognize that nail polish is a well-known factor that interferes with the accuracy of pulse oximeters.
Eliminate options that are either irrelevant (inserting an IV line) or insufficient to solve the primary problem (hand washing/sanitizing).
Conclude that the most critical action to ensure a reliable measurement is to remove the source of interference.

Concept Tested & Keywords

Concept Tested: Factors affecting the accuracy of pulse oximetry.
Stem keywords: pulse oximetry, oxygen, newly married patient
Lead-in keywords: should do
Clinical cues: The phrase 'newly married patient' is a cultural cue suggesting the potential presence of nail polish or henna, which can interfere with pulse oximeter readings.

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E6 Nursing Fundamentals Taylor p. 742-744

E6 Nursing Fundamentals Potter Perry 12e Part 3 p. 47-49