A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?
Remove the nasal cannula while the client eats.
Attach a humidifier bottle to the base of the flow meter.
Secure the oxygen tubing to the bed sheet near the client's head.
Apply petroleum jelly to the nares as needed to soothe mucous membranes.
The Correct Answer is B
A humidifier bottle adds moisture to the oxygen, which prevents drying and irritation of the nasal mucosa
and enhances gas exchange.
a. Remove the nasal cannula while the client eats. This is not advisable, as the client may become hypoxic during eating, especially if they have pneumonia and impaired lung function. The nurse should monitor the client's oxygen saturation and respiratory status during meals and adjust the oxygen delivery device as needed.
c. Secure the oxygen tubing to the bed sheet near the client's head. This is not safe, as it can cause entanglement, dislodgement, or kinking of the tubing, which can compromise oxygen delivery and cause injury to the client.
d. Apply petroleum jelly to the nares as needed to soothe mucous membranes. This is not recommended, as petroleum products can ignite in the presence of oxygen and cause burns or fire. A water-based lubricant should be used instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A humidifier bottle adds moisture to the oxygen, which prevents drying and irritation of the nasal mucosa
and enhances gas exchange.
a. Remove the nasal cannula while the client eats. This is not advisable, as the client may become hypoxic during eating, especially if they have pneumonia and impaired lung function. The nurse should monitor the client's oxygen saturation and respiratory status during meals and adjust the oxygen delivery device as needed.
c. Secure the oxygen tubing to the bed sheet near the client's head. This is not safe, as it can cause entanglement, dislodgement, or kinking of the tubing, which can compromise oxygen delivery and cause injury to the client.
d. Apply petroleum jelly to the nares as needed to soothe mucous membranes. This is not recommended, as petroleum products can ignite in the presence of oxygen and cause burns or fire. A water-based lubricant should be used instead.
Correct Answer is ["A","C","E"]
Explanation
These clients have impaired swallowing, gag reflex, or level of consciousness, which increase their risk of aspiration while eating.
The other options are not correct because:
b. A client who has had prolonged diarrhea does not have a direct risk factor for aspiration, as diarrhea affects the lower gastrointestinal tract and not the upper airway or esophagus.
d. A client who has lactose intolerance does not have a risk factor for aspiration, as lactose intolerance causes abdominal cramps, bloating, gas, or diarrhea when consuming dairy products, but does not affect the ability to swallow or protect the airway.
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