A nurse is planning care for a client who is to be discharged with home oxygen. Which of the following information should the nurse include in the plan of care?

Provide supplies for humidification for a client who is receiving oxygen at less than 4 L/min.

Secure the oxygen tank against the bed.

Provide the client with a petroleum-based lubricant for their nares.

Check the gauge daily for the amount of oxygen remaining in the tank..

Answer and Explanation

The Correct Answer is D

Rationale:

A. Humidification is not routinely required for low-flow oxygen therapy (typically ≤ 4 L/min via nasal cannula). It is generally considered when oxygen is delivered at higher flow rates or when the client experiences dryness or thick secretions. Routine humidification at low flow is not necessary.

B. Oxygen tanks should never be secured to a bed because beds are movable. If the bed is moved, the unsecured tank could fall or become damaged, creating a safety hazard. Oxygen cylinders should be secured in a stable, upright position using a proper stand or holder.

C. Petroleum-based products are flammable and should never be used with oxygen therapy due to the increased risk of combustion. Water-soluble lubricants should be used instead to reduce dryness of the nasal mucosa.

D. Clients on home oxygen therapy should be taught to monitor the oxygen cylinder gauge regularly (often daily) to ensure an adequate supply and to prevent unexpected depletion. This is an important safety measure for continuous oxygen availability.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","E","H"]

Explanation

Rationale:
A. A blood pressure of 148/94 mm Hg at 30 weeks’ gestation is elevated and concerning for gestational hypertension or preeclampsia. In combination with other findings (headache, right upper quadrant pain, edema, hyperreflexia), this requires immediate follow-up.

B. The client has 1+ dependent edema, which in pregnancy—especially when paired with hypertension and other symptoms—can indicate fluid retention associated with preeclampsia. This finding should be further evaluated for progression or worsening edema.

C. A fetal heart rate of 140/min is within the normal range (110–160/min), and no contractions are noted. At this time, there is no indication of fetal distress based on the provided information.

D. A rapid weight gain of 0.68 kg (1.5 lb) in one week during pregnancy can indicate fluid retention, which is a concerning sign of preeclampsia when combined with hypertension and edema.

E. Nausea and vomiting in the second half of pregnancy, especially with right upper quadrant pain and hypertension, can indicate liver involvement from severe preeclampsia (possible HELLP syndrome). This requires prompt follow-up.

F. A fundal height of 29 cm at 30 weeks’ gestation is appropriate (fundal height in cm approximately equals gestational age ± 2 cm), so this finding is expected.

G. Respirations are even and nonlabored with clear lung sounds and normal oxygen saturation, indicating no respiratory compromise at this time.

H. Deep tendon reflexes of 3+ indicate hyperreflexia, which is a hallmark sign of worsening preeclampsia and possible impending seizures (eclampsia). This requires urgent follow-up.

A. "Continuous PCA infusion is designed to allow fluctuating plasma medication levels." B. "You should push the button before physical activity to allow maximum pain control." C. "You can adjust the amount of pain medication you receive by pushing on the keypad." D. "The PCA will deliver a double dose of medication when you push the button twice."

Correct Answer is B

Explanation

Rationale:
A. PCA (patient-controlled analgesia) is designed to maintain relatively stable plasma drug levels by providing a basal (continuous) infusion and/or patient-activated bolus doses. The goal is to prevent peaks and troughs in pain control, not to create fluctuating medication levels.

B. Clients are taught to anticipate pain and use the PCA button before activities such as ambulation, coughing, or turning. This allows the medication time to take effect and provides better pain control during movement or procedures.

C. Clients do not control the dosage amount or settings of the PCA. The healthcare provider prescribes the dose limits, lockout interval, and basal rate if ordered. The client can only self-administer preset doses by pressing the button.

D. PCA devices have lockout intervals that prevent additional doses from being delivered too close together. Pressing the button multiple times will not result in a double dose; it will only deliver medication according to the preset safety parameters.

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