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. High doses of fish oil can indeed increase the risk of bleeding, particularly because fish oil has anticoagulant properties that can interfere with blood clotting. This risk is especially significant if the client is also taking other anticoagulant or antiplatelet medications.
B. While it is true that fish can be heart-healthy due to its omega-3 fatty acids, this statement does not fully address the concerns about the safety of high doses of fish oil supplements. Eating fish in moderate amounts is beneficial, but the focus here is on the effects of large doses of fish oil supplements, not just consuming fish. The safety of high doses should be considered separately.
C. Encouraging the client to increase the dose of fish oil is not appropriate without considering potential side effects and risks. High doses of fish oil can lead to gastrointestinal symptoms like nausea, diarrhea, and indigestion.
D. Not all types of oils increase cholesterol and triglycerides. For instance, omega-3 fatty acids found in fish oil can actually help lower triglyceride levels and may have a positive effect on cholesterol levels.

A. 4+ pitting edema of both lower extremities. B. Hypoactive bowel sounds with infrequent bowel movements. C. Braden risk assessment scale rating score of ten. D. Warm, dry skin with a fever of 100.0° F (37.8° C).

Correct Answer is C

Explanation

A. Pitting edema, especially at a 4+ level, indicates significant fluid retention in the lower extremities. While this can be a concern for skin integrity and may contribute to skin breakdown due to increased pressure and reduced mobility, it is not the most direct indicator for turning schedules.
B. Hypoactive bowel sounds and infrequent bowel movements suggest gastrointestinal issues, such as constipation or reduced bowel motility. While these issues are important to address for overall client health, they do not directly impact the scheduling of turning to prevent pressure ulcers.
C. The Braden Risk Assessment Scale is a tool used to evaluate a client's risk for developing pressure ulcers. A score of 10 indicates a high risk for pressure ulcer development. This assessment directly informs the need for a more aggressive turning schedule and other preventive measures to protect skin integrity.
D. Warm, dry skin and a low-grade fever might indicate an infection or other underlying condition, but these factors are not the primary considerations for determining the turning schedule. While fever and skin temperature can be important for overall assessment and care, they do not directly impact the need for turning to prevent pressure ulcers.

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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.

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Naxlex Comprehensive Predictor Exams

A male client tells the nurse that he is taking large doses of a fish oil supplement to lower his triglyceride level. Which action should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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