After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?

Discontinue the use of the nasal cannula.

Apply lubricant to the cannula tubing.

Place padding around the cannula tubing.

Decrease the flow rate to 1 L/minute.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. Place padding around the cannula tubing.

Choice A rationale:

Discontinuing the use of the nasal cannula is not appropriate because the client still needs supplemental oxygen to maintain adequate oxygen saturation levels.

Choice B rationale:

Applying lubricant to the cannula tubing might help reduce friction but does not address the pressure that is causing the red mark.

Choice C rationale:

Placing padding around the cannula tubing helps to alleviate the pressure on the skin, which can prevent further irritation and allow the red mark to heal.

Choice D rationale:

Decreasing the flow rate to 1 L/minute could compromise the client’s oxygenation status, as the current flow rate is necessary to maintain an oxygen saturation level of 94%.

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Correct Answer is B

Explanation

Choice A reason: Observing the color and amount of urine is important for assessing kidney function and hydration status but is not the most critical intervention for hypokalemia, which can have immediate life-threatening cardiac effects.

Choice B reason: Determining the apical pulse rate and rhythm is the most important intervention. Hypokalemia can lead to serious cardiac arrhythmias, and the apical pulse is the most accurate non-invasive way to assess cardiac rhythm and rate.

Choice C reason: Comparing muscle strength bilaterally is important for assessing the impact of hypokalemia on muscle function, but it is not as immediately life-threatening as cardiac effects.

Choice D reason: Assessing the strength of deep tendon reflexes can help evaluate neuromuscular involvement in hypokalemia but is less critical than monitoring for cardiac arrhythmias.

A. Print the electronic medical record (EMR) from a backup server. B. Identify information as a late entry in the record. C. Wait for notification that the system has been rebooted. D. Notify the information services department of the situation.

Correct Answer is D

Explanation

Choice A reason: Printing the EMR from a backup server does not resolve the immediate issue of the system lockup and may not be possible if the system is down.

Choice B reason: Identifying information as a late entry is a step to take after the system issue has been resolved and does not address the current problem.

Choice C reason: Waiting for the system to be rebooted is passive and does not actively contribute to resolving the system lockup.

Choice D reason: Notifying the information services department is the first and most proactive step to take, as they are responsible for resolving technical issues with the EMR system.

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After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (K+) 3.5 to 5 mEq/L (3.5 to 5 mmol/L)

Correct Answer is B

Explanation

The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?

Correct Answer is D

Explanation

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