A nurse is caring for a client who is receiving oxygen via nasal cannula at 4 L/min. Which of the following actions should the nurse take?

Avoid the use of humidifiers.

Position the cannula prongs curving upward in the nose.

Clean the cannula prongs daily.

Keep the oxygen tubing off the floor.

Answer and Explanation

The Correct Answer is C

Clean the cannula prongs daily.

This is because the nasal cannula can become contaminated with bacteria and mucus, which can cause infection and irritation of the nasal mucosa. Cleaning the cannula prongs daily with soap and water can prevent these complications.

Choice A is wrong because humidifiers can help moisten the dry oxygen and prevent nasal dryness and bleeding. Humidifiers should be used for oxygen flow rates higher than 4 L/min.

Choice B is wrong because the cannula prongs should be positioned curving downward in the nose, not upward. This allows for better alignment with the natural direction of airflow and reduces the risk of dislodgement.

Choice D is wrong because keeping the oxygen tubing off the floor is not a specific action for nasal cannula use. It is a general safety measure to prevent tripping and contamination of the tubing.

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Correct Answer is D

Explanation

A client who is 1 day postpartum and has not voided in 8 hr. This client is at risk of urinary retention, bladder distension, and infection due to the effects of epidural anesthesia, perineal trauma, and fluid shifts after delivery. The nurse should assess the client’s bladder and catheterize if necessary.

Choice A is wrong because a client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus is showing a normal finding.

The fundus should descend about 1 to 2 cm per day after delivery and be nonpalpable by day 10.

Choice B is wrong because a client who is 3 days postpartum and has not had a bowel movement since prior to admission is not uncommon.

Constipation is a common problem after delivery due to decreased peristalsis, dehydration, and fear of pain.

The nurse should encourage fluid intake, fiber intake, and early ambulation to promote bowel function.

Choice C is wrong because a client who is 4 days postpartum and has lochia serosa is also showing a normal finding.

Lochia serosa is the pinkish-brown discharge that occurs from day 4 to 10 after delivery.

It consists of old blood, serum, leukocytes, and tissue debris.

A. Place the client’s bed in the low position. B. Encourage the client to wear socks when ambulating. C. Position the client’s bedside table at the foot of the bed. D. Raise four side rails on the client’s bed.

Correct Answer is A

Explanation

This is because lowering the bed reduces the risk of injury if the client falls out of the bed. It also makes it easier for the client to get in and out of the bed safely.

Choice B is wrong because wearing socks when ambulating can increase the risk of slipping and falling. The client should wear shoes or slippers with non-skid soles.

Choice C is wrong because positioning the client’s bedside table at the foot of the bed can create an obstacle for the client to walk around. The bedside table should be placed near the head of the bed and within reach of the client.

Choice D is wrong because raising four side rails on the client’s bed can be considered a form of restraint and can increase the risk of injury if the client tries to climb over them. The use of restraints should be avoided for clients with dementia, as they can cause agitation, confusion, and distress. Instead, other measures such as bed alarms, motion sensors, or frequent monitoring should be used to prevent falls.

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