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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Immunological Administer antihistamine
The correct answer is to administer antihistamine. Antihistamines can help alleviate symptoms of an allergic reaction, such as itching, hives, and swelling, by blocking the effects of histamine
released during the allergic response.
Cardiovascular
Monitor vital signs continuously
The correct answer is to monitor vital signs continuously. Continuous monitoring of vital signs, including blood pressure, heart rate, and oxygen saturation, is essential to detect any changes in the client's cardiovascular status, especially after experiencing adverse reactions to medication.
Provide warmth
Providing warmth can help improve peripheral circulation and comfort for the client, especially if they are experiencing symptoms such as dizziness or feeling cold due to a drop in blood pressure.
Respiratory
Assess lung sounds
The correct answer is to assess lung sounds. Assessing lung sounds can help determine if the client is experiencing any respiratory distress or complications, such as wheezing or crackles, which may indicate a need for further intervention or respiratory support.
Chest x-ray
Ordering a chest x-ray can help evaluate the client's respiratory status, especially if there are concerns about potential complications such as pneumonia or pulmonary edema. It allows for the assessment of lung fields and can provide valuable information about the client's respiratory function.
Correct Answer is D
Explanation
A. Provide high protein snacks. High protein snacks may exacerbate the symptoms of CKD by increasing urea and creatinine levels further. It is not recommended.
B. Administer PRN oxygen. Oxygen therapy is not indicated based on the symptoms described and the laboratory findings of elevated BUN and serum creatinine.
C. Monitor glucose levels every 4 hours. Monitoring glucose levels is not directly related to the symptoms described or the laboratory findings associated with CKD.
D. Schedule frequent rest periods. Fatigue and difficulty concentrating are common symptoms of CKD due to the buildup of waste products in the blood. Scheduling frequent rest periods can
help alleviate these symptoms and improve the client's overall well-being.
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