The nurse notices redness under the chin of a client who is receiving oxygen at 2 L/minute via a nasal cannula. What action should the nurse take?

Cease the use of the nasal cannula.

Reduce the flow rate to 1 L/minute.

Apply lubricant to the cannula tubing.

Attach padding around the cannula tubing.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Ceasing the use of the nasal cannula would interrupt the client’s oxygen therapy, which could potentially worsen their condition. Therefore, this is not the best course of action.
Choice B rationale
Reducing the flow rate to 1 L/minute may not be appropriate as the client’s oxygen needs may not be met at a lower flow rate. The redness under the chin is likely due to the friction from the cannula tubing, not the flow rate of the oxygen.
Choice C rationale
Applying lubricant to the cannula tubing may not be effective in preventing skin breakdown and could potentially cause additional discomfort or complications for the client.
Choice D rationale
Attaching padding around the cannula tubing can help reduce the friction between the tubing and the skin, which can help prevent skin breakdown. This is the most appropriate action to take in this situation.

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Correct Answer is D

Explanation

Choice A rationale

Keeping the head of the bed raised 45 degrees can help improve lung expansion and reduce the risk of aspiration, which is particularly important for patients who are intubated or receiving enteral nutrition. However, it is not the most important intervention for a patient with septic shock.
Choice B rationale
Monitoring the patient’s blood glucose level is important, especially if the patient is receiving insulin or parenteral nutrition, as these can increase blood glucose levels. However, it is not the most important intervention for a patient with septic shock.
Choice C rationale
Assessing the warmth of the patient’s extremities can provide information about peripheral perfusion and may be useful in monitoring the patient’s response to treatment. However, it is not the most important intervention for a patient with septic shock.
Choice D rationale
This is the correct answer. Maintaining strict intake and output is crucial in managing a patient with septic shock. Fluid balance is a key component of managing septic shock, and accurate intake and output measurements are essential for guiding fluid resuscitation and assessing the patient’s response to treatment.

A. Perform a thorough physical assessment B. Develop a safety plan C. Take photographs to document the abuse or neglect D. Confront the abuser about concerning actions E. he client in front of the suspected abuser F. Complete a comprehensive history G. Throw away soiled clothing

Correct Answer is ["A","B","C","F"]

Explanation

Choice A rationale
Performing a thorough physical assessment is crucial when elder mistreatment is suspected. It helps to identify any signs of physical abuse or neglect.
Choice B rationale
Developing a safety plan is an important step in ensuring the safety of the elder. This plan can include strategies to avoid potential harm and steps to take if the elder feels unsafe.
Choice C rationale

Taking photographs to document the abuse or neglect can provide concrete evidence of the mistreatment. These photographs can be used in investigations and legal proceedings.
Choice F rationale
Completing a comprehensive history is necessary to understand the full context of the elder’s situation. This includes the elder’s health status, living conditions, and the nature of their relationship with the caregiver.
Choice H rationale
Reporting findings to Adult Protective Services is a critical step in addressing elder mistreatment. Adult Protective Services can conduct further investigations and take necessary actions to protect the elder.

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The nurse notices redness under the chin of a client who is receiving oxygen at 2 L/minute via a nasal cannula. What action should the nurse take?

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Naxlex Comprehensive Predictor Exams

A patient admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is D

Explanation

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Correct Answer is ["A","B","C","F"]

Explanation

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The nurse notices redness under the chin of a client who is receiving oxygen at 2 L/minute via a nasal cannula. What action should the nurse take?