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.

Answer and Explanation

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

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Correct Answer is A

Explanation

Choice A rationale

The first action the nurse should take when finding a patient on the floor is to check the patient for injuries. This is important to determine the extent of any potential harm and to guide subsequent actions.

Choice B rationale

Moving hazardous objects away from the patient is important, but it is not the first action the nurse should take. The nurse should first assess the patient for injuries.

Choice C rationale

Notifying the provider is an important step when a patient falls, but it is not the first action the nurse should take. The nurse should first assess the patient for injuries.

Choice D rationale

Asking the patient to describe how they felt prior to the fall is part of the assessment after a fall, but it is not the first action the nurse should take. The nurse should first assess the patient for injuries.

A. Insert the catheter at a 45-degree angle. B. Position the client’s arm in a dependent position. C. Remove excess hair from the insertion site. D. Initiate IV therapy in the veins of the hand.

Correct Answer is B

Explanation

Choice A rationale

Inserting the catheter at a 45-degree angle is not recommended for an older adult client with fragile skin. A lower angle of insertion is usually more appropriate.

Choice B rationale

Positioning the client’s arm in a dependent position can help engorge the veins, making it easier to insert the IV catheter.

Choice C rationale

Removing excess hair from the insertion site is not the first action the nurse should take. While it’s important to have a clean and clear insertion site, positioning the client’s arm correctly is a more immediate concern.

Choice D rationale

Initiating IV therapy in the veins of the hand is not the first action the nurse should take. While the veins of the hand can be used for IV insertion, positioning the client’s arm correctly is a more immediate concern.

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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?