A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?

Remove the nasal cannula while the client eats.

Attach a humidifier bottle to the base of the ﬂow meter.

Secure the oxygen tubing to the bed sheet near the client's head.

Apply petroleum jelly to the nares as needed to soothe mucous membranes.

Answer and Explanation

The Correct Answer is B

A humidifier bottle adds moisture to the oxygen, which prevents drying and irritation of the nasal mucosa

and enhances gas exchange.

a. Remove the nasal cannula while the client eats. This is not advisable, as the client may become hypoxic during eating, especially if they have pneumonia and impaired lung function. The nurse should monitor the client's oxygen saturation and respiratory status during meals and adjust the oxygen delivery device as needed.

c. Secure the oxygen tubing to the bed sheet near the client's head. This is not safe, as it can cause entanglement, dislodgement, or kinking of the tubing, which can compromise oxygen delivery and cause injury to the client.

d. Apply petroleum jelly to the nares as needed to soothe mucous membranes. This is not recommended, as petroleum products can ignite in the presence of oxygen and cause burns or fire. A water-based lubricant should be used instead.

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Correct Answer is C

Explanation

Agitation is a sign of hypoxemia, as the brain is deprived of oxygen and becomes irritable and restless.

The other options are not correct because:

Nausea is not a specific manifestation of hypoxemia, as it can have many other causes such as medication side eﬀects, gastrointestinal disorders, or anxiety.
Dysphagia is difficulty swallowing, which is not related to hypoxemia or asthma. It can be caused by neurological, muscular, or structural problems in the throat or esophagus.
Hypotension is low blood pressure, which is not a typical manifestation of hypoxemia or asthma. It can be caused by dehydration, blood loss, shock, or heart failure.

A. The medication will prevent wheezing. B. The medication will decrease coughing episodes. C. The medication will reduce inﬂammation. D. The medication will open the airways. E. The medication will stimulate ﬂow of mucus.

Correct Answer is ["A","D"]

Explanation

These responses are correct and explain how albuterol helps the client's breathing. Albuterol is a short- acting beta2-agonist that causes bronchodilation and relieves bronchospasm, which are the main causes of wheezing and dyspnea in clients who have asthma or COPD. By opening the airways, albuterol improves gas exchange and oxygenation.

b) The medication will decrease coughing episodes. This response is incorrect and does not explain how albuterol helps the client's breathing. Albuterol does not have a direct eﬀect on coughing, which is a reﬂex response to irritation or obstruction of the airways. Coughing may be beneficial for clearing secretions and mucus from the lungs, but it may also cause bronchoconstriction and inﬂammation. The nurse should advise the client to use other measures to decrease coughing, such as drinking ﬂuids, using a humidifier, or taking an expectorant.
c) The medication will reduce inﬂammation. This response is incorrect and does not explain how albuterol helps the client's breathing. Albuterol does not have an anti-inﬂammatory eﬀect on the airways, which are often inﬂamed and swollen in clients who have asthma or COPD. Inﬂammation can contribute to airway obstruction and mucus production, which impair gas exchange and oxygenation. The nurse should inform the client that albuterol is used for quick relief of acute symptoms, but not for long-term control or prevention of inﬂammation. The client may need to use another medication, such as an inhaled corticosteroid, to reduce inﬂammation.
e) The medication will stimulate ﬂow of mucus. This response is incorrect and does not explain how albuterol helps the client's breathing. Albuterol does not have a direct eﬀect on mucus production or clearance, which are often increased in clients who have asthma or COPD. Mucus can cause airway obstruction and infection, which impair gas exchange and oxygenation. The nurse should advise the client to use other measures to stimulate ﬂow of mucus, such as drinking ﬂuids, using a humidifier, or taking an expectorant.

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A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?

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