A patient has an order for an ABG (Arterial Blood Gas). The seasoned nurse explains to the new nurse that (Select All that Apply):

Choice A rationale

Oxygen is a powerful catalyst for combustion, meaning it helps fires burn hotter and faster. Posting signs is a critical safety intervention to prevent open flames or smoking near the oxygen source. Even small sparks can lead to rapid fire spread in an oxygen-enriched environment. This education is vital for home safety, as many residential fires involving medical oxygen result from smoking, leading to severe thermal injuries or death for the oxygen user.

Choice B rationale

Petroleum-based products, such as ointments or jellies, are flammable and should never be used near oxygen therapy. In the presence of high oxygen concentrations, these products can ignite spontaneously or fuel a fire if a spark occurs. Instead, water-based lubricants should be recommended to soothe dry or irritated nasal passages. Using petroleum products violates basic fire safety protocols for home oxygen use and poses a significant risk for facial burns and home fires.

Choice C rationale

Verifying the flow rate every other day is insufficient and unsafe for a patient requiring home oxygen therapy. The nurse should instruct the client to check the flow rate several times a day to ensure they are receiving the prescribed therapeutic dose. Consistent delivery of oxygen is necessary to maintain adequate arterial oxygen saturation. Checking only every other day increases the risk of the patient being hypoxic or receiving an incorrect dose for an extended period.

Choice D rationale

The tubing of a nasal cannula creates constant pressure on the skin behind and on top of the ears. Over time, this mechanical friction and pressure can lead to skin breakdown and the development of pressure ulcers. Regular skin assessments allow for early identification of redness or irritation. Interventions, such as using padded covers for the tubing, can then be implemented to protect the integrity of the skin and prevent painful tissue necrosis.

Choice E rationale

The position of the nasal cannula must be checked regularly because it can easily become dislodged during movement, sleep, or talking. If the prongs are not correctly positioned within the nares, the oxygen delivery becomes ineffective, leading to a drop in the patient's oxygen saturation levels. Ensuring the prongs are curved downward and properly seated in the nostrils is essential for the consistent administration of the prescribed 5 L per min of supplemental oxygen.

Choice A rationale

Weight gain is not associated with pulmonary tuberculosis because the infection triggers a systemic inflammatory response and a hypermetabolic state. The body consumes energy stores to fight the Mycobacterium tuberculosis pathogen, often leading to significant, unintended weight loss rather than gain. Additionally, cytokines like tumor necrosis factor-alpha contribute to anorexia and cachexia. In clinical practice, documenting a patient's weight is crucial as progressive loss often indicates disease activity or poor response to treatment.

Choice B rationale

A low-grade afternoon fever is a classic systemic manifestation of tuberculosis. This occurs because the immune system releases pyrogens in response to the replicating bacteria, which resets the hypothalamic thermostat. This fever typically peaks in the late afternoon or evening and may be accompanied by malaise. While high fevers can occur in acute stages, the persistent low-grade nature is more characteristic of the chronic inflammatory process seen in pulmonary tuberculosis infections during the active phase.

Choice C rationale

Blood in the sputum, or hemoptysis, occurs when the tuberculous process causes necrosis and cavitation within the lung parenchyma. As these cavities form, they can erode into small pulmonary blood vessels, leading to the expectoration of blood-streaked or frankly bloody mucus. This is a significant clinical indicator of tissue destruction and active disease. Nurses must monitor the amount and frequency of hemoptysis to assess the risk of airway obstruction or significant hemorrhage in these patients.

Choice D rationale

Night sweats are a hallmark symptom of tuberculosis resulting from the body's attempt to regulate temperature after a daytime low-grade fever. As the fever breaks during sleep, the diaphoresis becomes profuse, often soaking the client's clothes or bed linens. This symptom is linked to the circadian rhythm of cytokine release and the metabolic demands of the chronic infection. It is one of the most common subjective complaints that lead individuals to seek medical evaluation for tuberculosis.

Choice E rationale

Flushed cheeks are not a standard diagnostic finding for pulmonary tuberculosis. While a fever might cause transient redness, tuberculosis is more frequently associated with a pale or sallow complexion due to chronic anemia and general physical wasting, historically referred to as consumption. Flushed cheeks are more indicative of conditions causing acute high fever or mitral stenosis. In tuberculosis management, the focus remains on respiratory symptoms and systemic signs like weight loss and persistent cough rather than facial flushing.