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.
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%.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Skin turgor is a method to assess hydration status, but it is not the most accurate indicator of fluid balance in a patient with fluid volume overload.
Choice B reason: Monitoring weight is the most accurate method to assess fluid balance. A sudden increase or decrease in weight is indicative of fluid changes.
Choice C reason: Blood pressure can be affected by fluid volume changes, but it does not provide a direct measure of fluid balance.
Choice D reason: Lung sounds can indicate fluid overload in the lungs but do not give a complete picture of overall fluid balance.
Correct Answer is B
Explanation
Choice A reason: While using multiple people can increase safety, it is not the primary purpose of the log rolling technique.
Choice B reason: The log rolling technique is specifically designed to maintain straight spinal alignment, especially in patients with suspected spinal injuries, to prevent further injury.
Choice C reason: Reducing skin damage is a benefit of proper patient handling, but it is not the main reason for using the log rolling technique.
Choice D reason: Decreasing the risk of back injury to nurses is important, but the primary purpose of the log rolling technique is to protect the patient's spinal integrity.
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