The nurse observes an open skin lesion across the right zygomatic bone of a client receiving oxygen per nasal cannula at 4 L/minute. The client’s oxygen saturation level is 92%. Which intervention should the nurse implement?

Discontinue the use of the nasal cannula.

Place padding around the cannula tubing.

Apply lubricant to the cannula tubing.

Decrease the flow rate to 1 L/minute.

Answer and Explanation

The Correct Answer is B

Choice A reason: Discontinuing the nasal cannula risks worsening hypoxia, as the client’s oxygen saturation is 92%. The lesion is likely from tubing pressure, not oxygen delivery. Padding addresses the skin issue without compromising oxygenation, making discontinuation an inappropriate intervention that could harm the client’s respiratory status.

Choice B reason: Placing padding around the cannula tubing prevents further pressure on the zygomatic lesion, promoting skin healing. The lesion likely results from tubing friction or pressure. This intervention maintains oxygen delivery at 4 L/minute, ensuring the client’s 92% saturation is supported while addressing the skin integrity issue effectively.

Choice C reason: Applying lubricant to the cannula tubing may reduce friction but does not address pressure causing the lesion. Lubricants are more suitable for nasal dryness. Padding is more effective, as it cushions the tubing, preventing further skin breakdown while maintaining oxygen delivery for the client’s needs.

Choice D reason: Decreasing the flow rate to 1 L/minute may worsen hypoxia, as 4 L/minute maintains 92% saturation. The lesion is due to tubing pressure, not flow rate. Padding addresses the skin issue without altering oxygen therapy, making flow reduction an ineffective and potentially harmful intervention for this scenario.

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Correct Answer is B

Explanation

Choice A reason: Deep vein thrombosis causes pain and swelling but is not typically linked to sexual dysfunction. Sexual dysfunction often stems from vascular, neurological, or hormonal issues, like those associated with hypertension. DVT is unlikely to be noted in the record, as it lacks a direct physiological connection to the reported symptom.

Choice B reason: Hypertension is commonly associated with sexual dysfunction, as it impairs vascular function, reducing blood flow critical for sexual response. Medications like beta-blockers also contribute. The nurse should expect hypertension in the record, as it is a prevalent cause, supported by evidence linking cardiovascular health to sexual function.

Choice C reason: Fungal infections, like candidiasis, may cause localized discomfort but are not primary causes of sexual dysfunction. Dysfunction typically involves systemic or vascular issues, not superficial infections. The record is unlikely to note fungal infection as the cause, as it lacks a direct link to the client’s three-month history.

Choice D reason: Bacterial infections may cause systemic symptoms but are not strongly linked to sexual dysfunction unless involving the genitourinary tract, which is not specified. Hypertension is a more likely cause due to its vascular impact. The record is less likely to note bacterial infection as the primary contributor to this symptom.

A. Young adult client with chronic insomnia and atrial fibrillation being treated with warfarin. B. A client with restless leg syndrome and chronic obstructive pulmonary disease (COPD). C. An older adult client with multiple problems, including obesity, diabetes, and hypertension. D. A client who has a bleeding ulcer, high stress job, and takes flurazepam for sleep.

Correct Answer is C

Explanation

Choice A reason: Chronic insomnia and atrial fibrillation are not direct risk factors for sleep apnea. Warfarin treats clotting but does not affect airway obstruction. Sleep apnea is linked to obesity and anatomical factors, making this client less likely to require regular nighttime assessments compared to an obese, hypertensive client.

Choice B reason: Restless leg syndrome and COPD affect sleep and breathing but are not primary sleep apnea risk factors. COPD causes chronic airflow limitation, not intermittent airway collapse like apnea. Obesity is a stronger predictor, making the obese client with comorbidities a higher priority for regular sleep apnea assessments.

Choice C reason: Obesity, diabetes, and hypertension are strongly associated with obstructive sleep apnea, as excess weight narrows airways, causing intermittent collapse during sleep. Older adults are at higher risk due to reduced muscle tone. Regular nighttime assessments for snoring or apneic episodes are critical to detect and manage this condition, per evidence-based guidelines.

Choice D reason: A bleeding ulcer, high stress, and flurazepam use may disrupt sleep but are not specific to sleep apnea. Flurazepam, a sedative, may worsen undiagnosed apnea by relaxing airway muscles. Obesity remains a stronger risk factor, making the obese client with comorbidities the priority for regular apnea assessments.

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The nurse observes an open skin lesion across the right zygomatic bone of a client receiving oxygen per nasal cannula at 4 L/minute. The client’s oxygen saturation level is 92%. Which intervention should the nurse implement?

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Naxlex Comprehensive Predictor Exams

A client arrives to a clinic appointment reporting sexual dysfunction for the past three months. Which condition should the nurse expect to see in the client’s medical record?

Correct Answer is B

Explanation

The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea?

Correct Answer is C

Explanation

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The nurse observes an open skin lesion across the right zygomatic bone of a client receiving oxygen per nasal cannula at 4 L/minute. The client’s oxygen saturation level is 92%. Which intervention should the nurse implement?

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