Measuring Occult Blood in Stool & Measuring Oxygen Saturation with Pulse Oximetry & Monitoring Intake and Output

What is the initial step in preparing a fecal occult blood test?

Determine the patient’s ability to help obtain a sample.

The nurse has delegated to the unregulated care provider (UCP) the task of measuring occult blood in the stool of a patient with a history of positive results. Which instruction is most relevant to performing this test in this particular patient?

“Save the stool sample so that I can retest it if it is positive.”

Which instruction to the unregulated care provider (UCP) is most relevant to the proper performance of a fecal occult blood test using a hemoccult slide?

“Remember to take samples from two different areas of the specimen.”

Which statement indicates proper interpretation of the results of a positive fecal occult blood test?

“Because it was positive, the patient must be asked when they last ate red meat.”

Which of the following nursing actions addresses the risk for infection related to fecal occult blood testing?

Wearing clean gloves while testing

Which of the following is a risk factor for decreased oxygen saturation level in a patient?

Chest wall injury

What should the nurse teach an unregulated care provider (UCP) about selecting the appropriate site for measuring a patient’s oxygen saturation level?

“I’ve checked their capillary refill, and it’s acceptable in both their hands and feet.”

The nurse measures a patient’s oxygen saturation level as being 83%. What would the nurse do first?

Ask the patient whether they are having trouble breathing.

The nurse is preparing to measure the oxygen saturation level of a patient who is overweight. Which action would help ensure an adequate measurement?

Use a disposable tape-on sensor.

A patient is prescribed continuous oxygen saturation monitoring. The nurse would confirm that the alarms have been set to which limits?

Low of 85% and high of 100%

A patient is told the home care nurse will be measuring and recording intake and output (I&O) at home. What will the home care nurse do first?

Explain to the patient why I&O has been prescribed.

What measurements will the nurse direct an unregulated care provider (UCP) to measure for a hospitalized patient for whom I&O measurement is prescribed?

Urine collection drainage

Which statement reflects the nurse’s understanding of the importance of accurate urinary output measurement for a patient with acute renal failure?

“I will use a collection system with an hourly measurement device added.”

A patient has consumed three 100-mL cups of ice chips and 4 ounces of ginger ale. What will an unregulated care provider (UCP) document as this patient’s oral intake?

270 mL

A patient is admitted to your unit for dehydration. Which of the following assessments would the nurse identify as a possible sign of fluid imbalance?

Reduced turgor of the skin