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 ["A","B","C","D"]
Explanation
Choice A rationale
Regular inspection of the cord for frays or tears is crucial to ensure the safe operation of the home oxygen concentrator. A damaged cord can pose a risk of electric shock or fire.
Choice B rationale
Keeping the unit at least 1.2 m (4 ft) away from a gas stove is important because oxygen supports combustion. An oxygen-rich environment can cause materials to ignite more easily and make fires burn at a faster rate.
Choice C rationale
Considering the purchase of a generator for power backup is a good idea. In case of a power outage, a backup power source would ensure the continuous operation of the oxygen concentrator, which is critical for patients who are dependent on supplemental oxygen.
Choice D rationale
Monitoring for signs of hypoxia is essential. Despite receiving oxygen therapy, a patient may still experience hypoxia if the oxygen flow rate is insufficient, or if there are issues with the equipment. Signs of hypoxia include shortness of breath, rapid breathing, restlessness, confusion, and cyanosis (bluish color of the skin, lips, or nails)12.
Choice E rationale
Choosing synthetic clothing and bedding is not recommended. Synthetic materials can build up static electricity, which can spark and cause a fire in an oxygen-enriched environment.
Correct Answer is B
Explanation
Choice A rationale
The route of administration, “by mouth”, is clearly stated in the prescription. Therefore, there is no need to confirm this with the healthcare provider.
Choice B rationale
The dosage of the medication, “0.25”, is not specified in terms of units (e.g., milligrams, micrograms). This could lead to errors in medication administration. Therefore, the nurse should confirm the dosage of the medication with the healthcare provider.
Choice C rationale
The frequency of administration, “daily”, is clearly stated in the prescription. Therefore, there is no need to confirm this with the healthcare provider.
Choice D rationale
The name of the medication, “digoxin”, is clearly stated in the prescription. Therefore, there is no need to confirm this with the healthcare provider.
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