A nurse is performing a respiratory assessment.

During the exam, the nurse palpates subcutaneous air under the client's skin.

Which term would the nurse use when documenting this finding?

Choice A rationale

Removing the nasal cannula while the client eats is inappropriate for a patient requiring 5 L per min of oxygen. Eating is a physical activity that increases metabolic demands and oxygen consumption. If the cannula is removed, the patient may become acutely hypoxic during the meal. The design of the nasal cannula specifically allows the patient to talk and eat while still receiving continuous oxygen therapy, ensuring their saturation levels remain stable during these activities.

Choice B rationale

Securing the oxygen tubing to the bed sheet near the head is unsafe and restricts the client's movement. If the client turns or moves, the tubing could be pulled out or become kinked, interrupting the flow of oxygen. Furthermore, if the patient becomes entangled in the secured tubing, it could pose a strangulation risk or cause skin injury. Tubing should remain loose enough to allow for natural movement while ensuring the connection to the source remains intact.

Choice C rationale

Oxygen therapy at flow rates greater than 4 L per min can be very drying to the nasal mucosa, leading to discomfort, crusting, and potential epistaxis. Attaching a humidifier bottle to the flow meter adds moisture to the inspired gas, which protects the mucous membranes and improves patient comfort. For a prescription of 5 L per min, humidification is a standard nursing intervention to prevent the complications associated with the inhalation of dry, high-flow medical gases.

Choice D rationale

Applying petroleum jelly to the nares is contraindicated in patients receiving oxygen therapy. Petroleum is a combustible hydrocarbon that can easily ignite in an oxygen-rich environment, potentially causing severe burns to the patient's face and airway. To address dry or irritated mucous membranes, the nurse should use a water-soluble lubricant. These products provide the necessary moisture without the fire hazard associated with oil-based substances, ensuring both comfort and safety for the patient.

Choice A rationale

Neither of these medications is known to significantly alter glucose metabolism or cause hyperglycemia in a way that requires routine monitoring. While some medications can interfere with insulin sensitivity, these specific antituberculosis drugs do not have a primary side effect profile involving the endocrine pancreas. Monitoring sugar levels would only be necessary if the client had a pre-existing condition like diabetes mellitus. Therefore, this test is not a standard requirement for the general population taking this drug regimen.

Choice B rationale

Although these medications are processed by the body and can affect internal organs, they do not have a direct toxic effect on the gallbladder that would necessitate regular ultrasound or functional studies. Gallbladder issues usually manifest as biliary colic or cholecystitis, which are not common adverse reactions to these antibiotics. The primary focus of toxicity for these specific drugs is the parenchymal tissue of the organ responsible for metabolism rather than the storage of bile in the gallbladder.

Choice C rationale

These drugs do not interfere with the production or regulation of thyroid hormones. Hypothyroidism or hyperthyroidism are not recognized side effects of these medications. Routine testing of the hypothalamic-pituitary-thyroid axis is unnecessary unless the client presents with specific symptoms of metabolic dysfunction. Focus should remain on the organs known to be at risk for drug-induced injury. Thyroid function remains stable during typical courses of these medications, and resources should be directed toward more relevant monitoring.

Choice D rationale

Both of these medications are hepatotoxic and can cause significant injury to the cells of the liver. Pyrazinamide and rifampin can lead to drug-induced hepatitis, making it essential to monitor enzymes like alanine aminotransferase and aspartate aminotransferase. Normal ranges are typically 4 to 36 units per liter for ALT and 8 to 33 units per liter for AST. Regular testing allows for early detection of liver damage, ensuring the medication can be adjusted or stopped before permanent organ failure occurs.