The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3 L/minute, and the client's oxygen saturation level is 92%. Which intervention would the nurse implement?
Decrease the flow rate to 1 L/minute.
Place padding around the cannula tubing.
Apply lubricant to the cannula tubing.
Discontinue the use of the nasal cannula.
The Correct Answer is B
Choice A Reason: This is incorrect because decreasing the flow rate to 1 L/minute can compromise the client's oxygenation and worsen hypoxia. The client's oxygen saturation level is below the normal range of 95% to 100%.
Choice B Reason: This is correct because placing padding around the cannula tubing can prevent pressure ulcers and skin breakdown caused by friction and irritation from the tubing.
Choice C Reason: This is incorrect because applying lubricant to the cannula tubing can increase the risk of infection and inflammation of the nasal mucosa. Lubricant should be applied sparingly to the nares only if needed.
Choice D Reason: This is incorrect because discontinuing the use of the nasal cannula can endanger the client's life and cause respiratory failure. The client needs supplemental oxygen to maintain adequate oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is: d. Perform oropharyngeal suctioning.
Choice A: Irrigate the nasogastric tube with water
Reason: Irrigating the nasogastric tube with water is not appropriate when a client is choking and vomiting. This action could potentially worsen the situation by introducing more fluid into the stomach, increasing the risk of aspiration.
Choice B: Review the advance directive document
Reason: Reviewing the advance directive document is not an immediate action to take when a client is choking. Advance directives provide guidance on the client’s wishes for medical treatment but do not address acute emergency interventions.
Choice C: Elevate the head of bed 45 degrees
Reason: Elevating the head of the bed to 45 degrees can help reduce the risk of aspiration by using gravity to keep stomach contents down. However, this action alone is not sufficient to address the immediate choking hazard.
Choice D: Perform oropharyngeal suctioning
Reason: Performing oropharyngeal suctioning is the correct action because it directly addresses the choking hazard by clearing the airway of vomit and other obstructions. This is a critical step to ensure the client’s airway is clear and they can breathe properly.
Correct Answer is D
Explanation
Choice A: Massage the injection site to increase absorption is not a correct instruction because it may cause bruising and bleeding. Low-molecular-weight heparin is absorbed quickly without massaging.
Choice B: Rotate injections between the abdomen and gluteal areas is not a correct instruction because it may increase the risk of hematoma and infection. The abdomen is preferred over other sites for low-molecular-weight heparin injections.
Choice C: Expel the air in the prefilled syringe prior to injection is not a correct instruction because it may result in loss of medication and inaccurate dosing. The air bubble in the prefilled syringe should be left intact.
Choice D: Inject in abdominal area at least 2 inches from the umbilicus is a correct instruction because it ensures adequate subcutaneous tissue and avoids major blood vessels and organs.
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