The nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problem?

Correct Answer: C

Rationale: Pulse oximetry measures oxygen saturation but can be inaccurate with hypotension (C), as low blood pressure reduces peripheral perfusion, skewing readings. Fever (A) may increase metabolic demand but doesn't directly affect accuracy. Epilepsy (B) impacts neurological status, not perfusion. Respiratory failure (D) alters oxygenation but not oximetry reliability unless perfusion is compromised. C is correct. Rationale: Hypotension decreases blood flow to capillaries where oximeters detect hemoglobin saturation, leading to falsely low or erratic results, a known limitation per critical care monitoring standards. Nurses must correlate oximetry with clinical signs and possibly arterial blood gases (ABGs) in such cases, ensuring accurate respiratory assessment post-tracheostomy, unlike the other conditions which don't directly impair device function.

Correct Answer: A

Rationale: GCS of 8 indicates severe injury; preparing for intubation (A) protects the airway. Ambulation (B), fluids (C), or bath (D) are inappropriate. A is correct. Rationale: GCS ≤8 risks airway compromise, requiring intubation readiness, per trauma care standards, prioritizing safety.

Correct Answer: A

Rationale: Hildegard Peplau's Interpersonal Relations Model centers on the individual, emphasizing the nurse-client relationship as a therapeutic tool for personal growth and problem-solving. Unlike models targeting communities or families, Peplau's framework views nursing as an interpersonal process where the nurse supports the client's emotional and health needs through phases like orientation and resolution. For instance, helping a client cope with anxiety post-diagnosis focuses on their unique experience, not broader societal dynamics. This individual focus distinguishes her theory, fostering tailored interventions that enhance client autonomy and well-being in clinical practice.

Correct Answer: B

Rationale: Reducing iatrogenic infections those caused by healthcare requires proper IV procedures, as catheter sites are common infection entry points. Correct technique, like sterile insertion and maintenance, prevents pathogen introduction. Teaching hand washing helps clients but not staff-related infections, while bagging linens or isolating TB addresses specific cases, not broad iatrogenic risks. This action directly lowers infection rates tied to nursing interventions.

Correct Answer: B

Rationale: The skin, the largest organ, protects and regulates, unlike intestines or kidneys. Nurses prioritize skin care for its extensive role in health.