The nurse observes erythema under the chin of a client receiving oxygen at 2 L/minute per nasal cannula. Which intervention should the nurse implement?

A Place padding around the cannula tubing.

B Decrease the flow rate to 1 L/minute.

C Apply lubricant to the cannula tubing.

D Discontinue the use of the nasal cannula.

Answer and Explanation

The Correct Answer is A

A.   Placing padding around the cannula tubing is the appropriate intervention to address the erythema under the chin. This padding can help alleviate pressure and reduce skin irritation caused by the tubing. It's a proactive measure to prevent further discomfort or skin breakdown.
B.   Decreasing the flow rate to 1 L/minute might not address the issue of pressure-related erythema, and it could compromise the client's oxygenation if not clinically indicated.
C.   Applying lubricant to the tubing may not effectively reduce pressure or irritation caused by the tubing under the chin.
D.   Discontinuing the use of the nasal cannula should be reserved for situations where it is medically necessary or if an alternative oxygen delivery method is available.

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Correct Answer is D

Explanation

A. "How do you cope with the voices?" is an important question to assess the client's coping mechanisms, but it does not provide direct information about the content or nature of the auditory hallucinations. While coping strategies are relevant, understanding the nature of the hallucinations is crucial for treatment planning.

B. "When do you hear voices?" is important to understand the timing and frequency of the hallucinations, but it does not provide information about the content or nature of the hallucinations themselves.

C. "Which medication works best?" is important to assess the client's previous treatment history and response to medication, but it does not directly address the current assessment of the auditory hallucinations.

D. "What are the voices saying?" is the most important question because it directly addresses the content and nature of the auditory hallucinations. Understanding the specific content, tone, and perceived significance of the voices can provide valuable information for diagnosis, treatment planning, and assessing the client's level of distress or impairment.

Correct Answer is ["100"]

Explanation

Total volume of the infusion: 50 mL (saline bag)
Infusion time: 30 minutes = 0.5 hours (convert minutes to hours)
We don't need the concentration of gentamicin for this calculation because we're only interested in the total volume delivered per hour.
Flow rate: Since all the medication is delivered within the infusion time, the flow rate is equal to the total volume divided by the infusion time.

Flow rate (mL/hour) = Total volume (mL) / Infusion time (hours)

Flow rate = 50 mL / 0.5 hours Flow rate = 100.0 mL/hour

Therefore, the nurse should set the pump to deliver 100.0 mL/hour to infuse the 60 mg of gentamicin over 30 minutes.

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The nurse observes erythema under the chin of a client receiving oxygen at 2 L/minute per nasal cannula. Which intervention should the nurse implement?

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Naxlex Comprehensive Predictor Exams

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the nurse to include in the assessment of this client?

Correct Answer is D

Explanation

Correct Answer is ["100"]

Explanation

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