The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe? Select all that apply.

Over the cheeks.

Around the nostrils.

Across the forehead.

Bridge of the nose.

Tops of the ears.

Answer and Explanation

Correct Answer : A,B,D,E

A.   The cheeks can be affected by the nasal cannula, especially if it is not positioned properly or if it causes irritation over time.
B.   The area around the nostrils is one of the most common sites for skin damage related to nasal cannulas. Continuous contact with the cannula can cause irritation, redness, or even sores in this area.
C.   The nasal cannula itself does not typically make contact with the forehead. Therefore, skin damage across the forehead is not generally a concern related to the use of a nasal cannula.
D.   The bridge of the nose is a key area to inspect for skin damage. The nasal cannula’s prongs often rest on or near the bridge of the nose, which can lead to pressure sores, redness, or irritation in this area. Regular assessment is important to prevent and address any damage.
E.   The tops of the ears can be affected if the nasal cannula’s tubing or securing mechanism (such as behind-the-ear supports or loops) causes friction or pressure. Skin breakdown can occur in this area if the cannula is not properly adjusted or if it causes irritation.

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Correct Answer is A

Explanation

A. Asking the client to describe the pain is the most direct way to gather information about the quality of the pain. This approach allows the client to express characteristics such as whether the pain is sharp, dull, burning, aching, throbbing, or stabbing.
B. A visual analog scale (VAS) is useful for assessing the intensity of pain, not the quality. The VAS typically involves a line with endpoints representing no pain and worst possible pain, where the client marks their pain level.
C. The numeric pain scale is designed to measure the intensity of pain on a scale from 0 to 10, where 0 indicates no pain and 10 represents the worst pain imaginable. Like the VAS, this scale assesses pain intensity rather than quality.
D. Palpation and observing the client's response can help assess the location and intensity of pain, particularly if there are physical findings associated with the pain. However, this method does not provide information about the pain’s quality, such as its character or nature.

A. Explain the respiratory problems that can occur with morphine use. B. Recommend asking the healthcare professional for a patient-controlled analgesia (PCA) pump. C. Provide client with a schedule of around-the-clock prescribed analgesic use. D. Teach family how to evaluate the effectiveness of analgesics.

Correct Answer is C

Explanation

A. Morphine is a potent opioid used for pain relief, but it can have side effects, including respiratory depression. While it is important to be aware of and discuss potential side effects, focusing on
respiratory problems might increase the client’s anxiety about using the medication.
B. A PCA pump allows patients to self-administer pain medication within prescribed limits, providing more control over pain management. However, PCA pumps are typically used in hospital settings and may not be practical or appropriate for home hospice care.
C. Providing a schedule for around-the-clock analgesic use is a practical and effective approach to pain management. It ensures that the client receives consistent pain relief and helps prevent the pain from becoming unmanageable.
D. Teaching the family to evaluate the effectiveness of analgesics is important for ongoing pain management. This includes recognizing signs of pain relief and potential side effects. However, this action might be more relevant once pain management is underway and requires follow-up, rather than addressing the immediate concern of managing pain effectively from the start.

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The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a client's pain, the nurse determines the location and intensity of the pain. To gather data about the quality of the pain, which action should the nurse take?

Correct Answer is A

Explanation

In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?

Correct Answer is C

Explanation

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