A nurse is caring for a client who is receiving oxygen via nasal cannula at 4 L/min. Which of the following actions should the nurse take?

Avoid the use of humidifiers.

Position the cannula prongs curving upward in the nose.

Clean the cannula prongs daily.

Keep the oxygen tubing off the floor.

Answer and Explanation

The Correct Answer is C

Clean the cannula prongs daily.

This is because the nasal cannula can become contaminated with bacteria and mucus, which can cause infection and irritation of the nasal mucosa. Cleaning the cannula prongs daily with soap and water can prevent these complications.

Choice A is wrong because humidifiers can help moisten the dry oxygen and prevent nasal dryness and bleeding. Humidifiers should be used for oxygen flow rates higher than 4 L/min.

Choice B is wrong because the cannula prongs should be positioned curving downward in the nose, not upward. This allows for better alignment with the natural direction of airflow and reduces the risk of dislodgement.

Choice D is wrong because keeping the oxygen tubing off the floor is not a specific action for nasal cannula use. It is a general safety measure to prevent tripping and contamination of the tubing.

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Correct Answer is D

Explanation

The nurse should instruct the client to avoid bananas because they are one of the foods that can cause a cross-reaction with latex allergy. This means that people who are allergic to latex may also have an allergic reaction to bananas because they contain similar proteins.

Choice A is wrong because wheat is not a latex cross-reactive food.

Choice B is wrong because strawberries are a low or undetermined cross- reactive food.

Choice C is wrong because peanuts are a low or undetermined cross-reactive food.

Some other foods that the nurse should instruct the client to avoid are avocado, kiwi, chestnut, papaya, and potato. These foods have a high or moderate association with latex cross-reactions. The client should also be careful with other fruits and vegetables that may contain similar proteins to latex.

A. A client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus. B. A client who is 3 days postpartum and has not had a bowel movement since prior to admission. C. A client who is 4 days postpartum and has lochia serosa. D. A client who is 1 day postpartum and has not voided in 8 hr.

Correct Answer is D

Explanation

A client who is 1 day postpartum and has not voided in 8 hr. This client is at risk of urinary retention, bladder distension, and infection due to the effects of epidural anesthesia, perineal trauma, and fluid shifts after delivery. The nurse should assess the client’s bladder and catheterize if necessary.

Choice A is wrong because a client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus is showing a normal finding.

The fundus should descend about 1 to 2 cm per day after delivery and be nonpalpable by day 10.

Choice B is wrong because a client who is 3 days postpartum and has not had a bowel movement since prior to admission is not uncommon.

Constipation is a common problem after delivery due to decreased peristalsis, dehydration, and fear of pain.

The nurse should encourage fluid intake, fiber intake, and early ambulation to promote bowel function.

Choice C is wrong because a client who is 4 days postpartum and has lochia serosa is also showing a normal finding.

Lochia serosa is the pinkish-brown discharge that occurs from day 4 to 10 after delivery.

It consists of old blood, serum, leukocytes, and tissue debris.

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A nurse is caring for a client who is receiving oxygen via nasal cannula at 4 L/min. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is D

Explanation

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