A nurse is caring for a patient who is receiving oxygen therapy via nasal cannula. The nurse notices that the patient's nares are dry and irritated. What should the nurse do first?
Apply petroleum jelly to the nares.
Increase the flow rate of oxygen.
Change the nasal cannula to a face mask.
Connect the device to a humidifier.
The Correct Answer is D
Choice D rationale:
The nurse should connect the nasal cannula to a humidifier first. Dry and irritated nares are common side effects of oxygen therapy via nasal cannula, and using a humidifier adds moisture to the oxygen, reducing irritation and discomfort for the patient.
Choice A rationale:
Applying petroleum jelly to the nares is not the first action to take. It might provide temporary relief, but it is essential to address the root cause of dryness, which is the lack of moisture in the oxygen delivered.
Choice B rationale:
Increasing the flow rate of oxygen is not the first step because it may not address the dryness issue. It can lead to a higher concentration of oxygen, but it won't solve the problem of dry and irritated nares.
Choice C rationale:
Changing the nasal cannula to a face mask is not necessary to address the dryness. Face masks may not be well-tolerated by some patients, and it's better to try less invasive interventions first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Nasal cannula delivers oxygen through two small prongs placed in the patient's nostrils. While it is a commonly used and well-tolerated device, the FiO2 delivered can vary significantly depending on the patient's breathing pattern and respiratory rate. Thus, it does not provide the most precise and consistent FiO2.
Choice B rationale:
Simple face masks cover the nose and mouth and can provide higher FiO2 levels compared to nasal cannulas. However, the FiO2 delivered still depends on the patient's breathing pattern and the mask's fit, making it less precise and consistent than other options.
Choice C rationale:
Venturi masks are designed to deliver a specific and accurate FiO2, regardless of the patient's breathing pattern. These masks have adjustable ports to control the mix of air and oxygen, providing precise oxygen concentrations.
Choice D rationale:
Non-rebreather masks have one-way valves and a reservoir bag to deliver higher concentrations of oxygen. Although they can provide high FiO2 levels, the delivered concentration can vary based on the patient's breathing pattern and the mask's fit.
Correct Answer is B
Explanation
Choice A rationale:
Refilling the oxygen tank based on the client's perception of it feeling light and empty is not a reliable method, as it may lead to running out of oxygen unexpectedly.
Choice B rationale:
The nurse should instruct the client to refill the oxygen tank when the pressure gauge reads below 500 psi. This is a standardized method to ensure the client does not run out of oxygen, as the pressure gauge provides an accurate measure of the remaining oxygen in the tank.
Choice C rationale:
Refilling the tank when a hissing sound is heard from the valve is not a valid method for determining the need for a refill and may result in running out of oxygen.
Choice D rationale:
Waiting for an alarm sound from the regulator to refill the tank is not recommended, as the tank could run out of oxygen before the alarm activates.
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