A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse.
Which of the following actions should the nurse include?
Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.
Ensure the reservoir bag of a partial rebreathing mask remains deflated.
Use petroleum jelly to lubricate the patient’s nares, face, and lips.
The Correct Answer is B
Choice A rationale
Regulating the flow rate by aligning the rate with the top of the ball inside the flow meter is a common practice in oxygen therapy. However, this action is not the most critical aspect to include when reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse.
Choice B rationale
Regulating oxygen via nasal cannula at a flow rate of no more than 6 L/min is indeed an important aspect of oxygen therapy. Oxygen delivered at higher rates using a traditional nasal cannula can dry out sinus passages and lead to nosebleeds. Nasal cannula is typically started at 2L/min and then titrated upwards to as high as 6L/min, although 2-4L/min is ideal. This delivers 25-40% FIO2, depending upon their respiratory rate, tidal volume, and amount of mouth breathing. Therefore, this action should be included when educating a newly licensed nurse about the administration of oxygen therapy.
Choice C rationale
Ensuring the reservoir bag of a partial rebreathing mask remains deflated is not a recommended practice. A partial rebreathing mask is a face mask with a reservoir bag that delivers moderate to higher concentrations of oxygen. Frequent inspection of the reservoir bag is required to ensure that it remains inflated; if it is deflated, exhaled air collects in it, which results in the patient rebreathing large amounts of exhaled carbon dioxide. Therefore, this action should not be included when educating a newly licensed nurse about the administration of oxygen therapy.
Choice D rationale
Using petroleum jelly to lubricate the patient’s nares, face, and lips is not recommended. Even though use of intranasal petroleum jelly is common, it is not recommended. The heaviness of the base does not allow normal secretion and/or absorption of fluids or medications. Vitamin E oil is a much more appropriate and equally available remedy. This lighter nonpetroleum lubricant has a natural emollient effect. Therefore, this action should not be included when educating a newly licensed nurse about the administration of oxygen therapy. Dressing Dressing Explore
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A patient being in a wheelchair with the wheels locked does not necessarily indicate elder abuse. It could simply mean that the patient has mobility issues and the wheelchair is a means of transportation for them. The wheels being locked could be a safety measure to prevent the wheelchair from moving unexpectedly.
Choice B rationale
The patient reporting receiving a full bath twice each week does not indicate elder abuse. In fact, it shows that the patient’s hygiene needs are being met regularly. Regular bathing is part of good personal hygiene and is important for overall health.
Choice C rationale
The caregiver insisting on staying in the room during the nurse’s assessment could be a potential sign of elder abuse. This could indicate that the caregiver is controlling or overbearing, and may be trying to monitor or control the patient’s interactions with others. It could also suggest that the caregiver is trying to hide something or prevent the patient from speaking freely.
Choice D rationale
The caregiver being the patient’s financial power of attorney does not necessarily indicate elder abuse. A financial power of attorney is a legal document that gives someone the authority to handle financial transactions on behalf of another person. It is often used when a person is unable to manage their own financial affairs due to illness or incapacity.
Correct Answer is ["A","B"]
Explanation
Choice A rationale
When a patient is placed on isolation precautions, the nurse should wear an N95 mask when caring for the patient. This is to protect the nurse from airborne particles that may be present in the patient’s environment.
Choice B rationale
Another important action the nurse should take is to place a container for soiled linens inside the patient’s room. This is to prevent the spread of infection from the patient’s room to other areas of the healthcare facility.
Choice C rationale
Wearing a sterile, water-resistant gown if within 3 feet of the patient is not necessary unless the patient has a condition that requires contact precautions, such as MRSA or VRE. In general, isolation precautions do not require the use of a sterile gown unless performing a sterile procedure.
Choice D rationale
Ensuring the patient’s room is well-ventilated is important for certain types of isolation precautions, such as airborne precautions for tuberculosis. However, it is not a standard action for all isolation precautions.
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