A nurse is providing reinforcing discharge instructions to a client who has a prescription for oxygen use at home.
Which of the following information should the nurse include? (Select all that apply.)

Family members who smoke must be at least 10 ft from the client when oxygen is in use.

Nail polish remover or hair spray should not be used near a client who is receiving oxygen.

A "No Smoking" sign should be placed on the front door.

Cotton bedding and clothing should be replaced with items made from wool.

A fire extinguisher should be readily available in the home.

Answer and Explanation

Correct Answer : D

Choice A rationale:

Tying the straps of the restraints in a double knot is incorrect. This action can make it difficult to quickly release the restraints in case of an emergency. A single, quick-release knot is recommended to ensure the client's safety.

Choice B rationale:

Tying the restraints to the side rails is incorrect. Attaching restraints to the side rails can cause injury to the client and is not a proper restraint application method. Restraints should be tied to the bed frame, not the side rails, to prevent harm.

Choice C rationale:

Placing the padding of the restraints against the client's bony prominences is incorrect. While padding is important to prevent skin breakdown and pressure ulcers, the correct placement of the padding alone does not indicate a comprehensive understanding of proper restraint application.

Choice D rationale:

Inserting one finger between the client's wrist and the restraint is the correct action. This technique ensures that the restraints are not too tight, allowing for proper circulation and preventing injury to the client. The ability to insert one finger indicates that the restraints are snug but not constrictive, maintaining the client's safety and comfort.

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Correct Answer is A

Explanation

Choice A rationale:

The client's respirations are faster and deeper than normal due to expelling too much carbon dioxide. This condition is known as hyperventilation. Hyperventilation can occur due to various reasons such as anxiety, pain, fever, or metabolic acidosis. When the body expels excessive carbon dioxide, it leads to respiratory alkalosis, resulting in faster and deeper breathing to compensate for the decrease in carbon dioxide levels in the blood.

Choice B rationale:

This option is incorrect. Hypoxemia, or low blood oxygen levels, typically leads to rapid, shallow breathing (tachypnea) rather than deep and fast respirations.

Choice C rationale:

This option is incorrect. Inflammation of the phrenic nerve does not directly affect the depth and rate of respirations. Phrenic nerve inflammation is more likely to cause pain during breathing or hiccups.

Choice D rationale:

This option is incorrect. Using intercostal muscles to breathe is a normal physiological process, especially during deep or labored breathing. However, it does not explain the specific situation described in the question, where the respirations are faster and deeper than normal.

A. Obtain the blood pressure first thing in the morning. B. Use the appropriate size cuff for the client. C. Make sure the client is relaxed and comfortable prior to obtaining the blood pressure. D. Remove the clothing from arms before obtaining the blood pressure.

Correct Answer is C

Explanation

Choice A rationale:

This option is incorrect. Tachypnea refers to abnormally fast breathing, typically defined as a respiratory rate higher than 20 breaths per minute in adults. It is the opposite of the condition described in the question, where the respiratory rate has fallen below 10 respirations per minute.

Choice B rationale:

This option is incorrect. Apnea refers to the absence of breathing, often resulting from a temporary cessation of airflow to the lungs. It is characterized by the complete absence of respiratory movements and sounds, which is different from the situation described in the question where the client is breathing at a very slow rate.

Choice C rationale:

Bradypnea, or abnormally slow breathing, is the correct answer in this case. It is defined as a respiratory rate lower than the normal range, which is typically between 12 to 20 breaths per minute in adults. Bradypnea can be caused by various factors, including drug overdose, neurological disorders, or metabolic imbalances. In this scenario, the client's slow respiratory rate (below 10 respirations per minute) indicates bradypnea.

Choice D rationale:

This option is incorrect. Eupnea refers to normal breathing, where the rate and depth of respirations are within the normal range. It does not describe the condition of the sedated client in the question, who is experiencing abnormally slow breathing (bradypnea)

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A nurse is providing reinforcing discharge instructions to a client who has a prescription for oxygen use at home.Which of the following information should the nurse include? (Select all that apply.)

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A nurse is providing reinforcing discharge instructions to a client who has a prescription for oxygen use at home.
Which of the following information should the nurse include? (Select all that apply.)