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 B

Explanation

A. Apply a water-soluble lubricant to the catheter. Lubricating the suction catheter can facilitate insertion, but applying a lubricant is not the primary action needed to address excessive drooling.
Additionally, water-soluble lubricants may not provide adequate protection against potential splashes or droplets.
B. Wear protective goggles while performing the procedure. Excessive drooling in a client with ALS may increase the risk of exposure to saliva and potential aerosolized droplets during
suctioning. Wearing protective goggles helps prevent exposure to bodily fluids and reduces the risk of infection for the nurse.
C. Instill 3 mL of normal saline before suctioning. Instilling normal saline before suctioning is not typically indicated for oral suctioning in a client with excessive drooling. This action may increase the risk of aspiration and is unnecessary for managing drooling.
D. Instruct the client to cough as the suction tip is removed. Instructing the client to cough is not appropriate for oral suctioning. Coughing may increase the production of saliva and exacerbate drooling. Additionally, this action does not address the nurse's safety during the suctioning
procedure.

A. Dosage in safe range B. Blood urea nitrogen 17 mg/dl. (6.07 mmol/L) C. Potassium 4.4 mEq/L (4.4 mmol/L) D. No known allergies E. Peripheral IV in large vein F. Used for prophylaxis

Correct Answer is ["A","B","D","E"]

Explanation

A. Dosage in safe range: Ensures that the dosage of vancomycin falls within the acceptable range, minimizing the risk of toxicity.
B. Blood urea nitrogen 17 mg/dl (6.07 mmol/L): Normal BUN levels indicate adequate renal function, which is important for the excretion of vancomycin.
C. Potassium 4.4 mEq/L (4.4 mmol/L): While potassium levels are important for overall health, they are not directly related to the administration of vancomycin.
D. No known allergies: Absence of allergies reduces the risk of adverse reactions to the medication.
E. Peripheral IV in large vein: A peripheral IV in a large vein allows for the administration of vancomycin without complications such as phlebitis or infiltration.
F. While vancomycin is being used for prophylaxis against endocarditis in this case, this alone does not indicate the safety of administering the antibiotic. Other factors such as renal function and absence of allergies are more directly related to the safety of vancomycin administration.

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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

The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

Correct Answer is B

Explanation

Exhibits Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

Correct Answer is ["A","B","D","E"]

Explanation

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