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 ["B","C","D"]
Explanation
Choice A rationale
The blood pressure of 114/86 mm Hg is within the normal range and does not require follow- up.
Choice B rationale
The oxygen saturation of 85% on room air is below the normal range of 95% to 100%, indicating the client may be experiencing hypoxemia, which requires follow-up.
Choice C rationale
The temperature of 38.6C (101.5° F) is slightly elevated, indicating the client may have a fever, which requires follow-up.
Choice D rationale
The heart rate of 99/min is slightly elevated, indicating the client may be experiencing tachycardia, which requires follow-up.
Correct Answer is C
Explanation
Choice A rationale: Group discussions represent the cognitive and affective domains of learning. They allow participants to share knowledge and feelings but do not involve the physical manipulation required for psychomotor skills.
Choice B rationale: Query and answer sessions focus on the cognitive domain. They address the learner's need for information and clarification of facts rather than the development of physical coordination or manual dexterity.
Choice C rationale: Practice sessions are the definitive psychomotor approach. They require the learner to physically perform a task, such as changing an ostomy appliance, to develop muscle memory and technical proficiency.
Choice D rationale: Role play primarily addresses the affective domain by exploring attitudes and behaviors. While it involves action, it focuses on social and emotional responses rather than specific technical or manual tasks.
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