The practical nurse (PN) checks the face of an older adult client who is wearing a nasal cannula. Which new finding is most important for the PN to report to the charge nurse?
Redness of the cheek under the cannula.
Dry, cracked mucous membranes.
Encrustations on both of the eyelids.
Drooping of the right side of the mouth.
The Correct Answer is D
A. Redness of the cheek under the cannula: Indicates skin irritation, but can usually be managed locally; not the most urgent.
B. Dry, cracked mucous membranes: Suggests dryness from oxygen but not immediately life-threatening.
C. Encrustations on both of the eyelids: Could indicate infection or poor hygiene but less urgent than neurological changes.
D. Drooping of the right side of the mouth: This could indicate a new-onset stroke (facial droop), which is a neurological emergency requiring immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Constipation and dietary modification:
Not the primary concern for endocarditis; activity tolerance is more important.
B. Sequencing activities with rest periods:
Clients with endocarditis experience fatigue due to infection and cardiac workload; rest is essential.
C. Oral antibiotic administration:
Route of administration is less important than ensuring completion of treatment, often given IV.
D. Personal hygiene and oral care:
Important but not the priority over conserving energy.
Correct Answer is C
Explanation
A. Add distilled water to the humidifier: Necessary for moisture, but oxygen delivery must be corrected first.
B. Place padding over reddened area: Helps prevent skin breakdown but does not address oxygen needs.
C. Increase the oxygen flow rate: Priority is to restore prescribed oxygen to prevent hypoxia.
D. Instruct client to increase fluid intake: Can help with dryness but is not urgent compared to correcting oxygen flow.
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