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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Administering a short-acting beta2-agonist (SABA), such as albuterol, is the priority intervention for the nurse to take, as it provides rapid bronchodilation and relieves bronchospasm, which are the main features of status asthmaticus. Status asthmaticus is a severe and life-threatening asthma attack that does not respond to usual treatment and requires immediate medical attention.

a) Determining the cause of the acute exacerbation is important, but not the priority intervention for the nurse to take. The cause may be an allergen, infection, stress, or exercise, but it does not aﬀect the immediate management of status asthmaticus. The nurse should focus on restoring airway patency and oxygenation first, and then identify and avoid triggers later.
b) Obtaining a peak ﬂow reading is important, but not the priority intervention for the nurse to take. The peak ﬂow reading measures the maximum expiratory ﬂow rate and indicates the degree of airway obstruction. However, it may not be feasible or accurate in a child who is experiencing status asthmaticus, as they may be too dyspneic or agitated to perform the test. The nurse should rely on other signs of respiratory distress, such as wheezes, retractions, cyanosis, or pulse oximetry.
c) Administering an inhaled glucocorticoid is important, but not the priority intervention for the nurse to take. Glucocorticoids, such as ﬂuticasone or budesonide, reduce inﬂammation and mucus production in the airways, but they have a delayed onset of action and are not eﬀective for acute asthma attacks. They are used for long-term control and prevention of asthma symptoms.

A. Patency of the intravenous line. B. Need for suctioning. C. Integrity of the dressing. D. Level of pain.

Correct Answer is B

Explanation

Suctioning is the priority observation in the client's care, as it prevents airway obstruction and respiratory distress caused by blood, mucus, or secretions. The client has a permanent tracheostomy and cannot cough

or clear the airway eﬀectively. The nurse should assess the need for suctioning frequently and perform it as needed, using sterile technique and maintaining oxygenation.

a) Patency of the intravenous line is important, but not the priority observation in the client's care. The intravenous line provides ﬂuids, electrolytes, and medications to the client, but it does not aﬀect the airway patency or oxygenation.
c) Integrity of the dressing is important, but not the priority observation in the client's care. The dressing protects the surgical site from infection and bleeding, but it does not aﬀect the airway patency or oxygenation.
d) Level of pain is important, but not the priority observation in the client's care. The pain can be managed with analgesics and nonpharmacological measures, but it does not aﬀect the airway patency or oxygenation.

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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?

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