A nurse is reinforcing teaching with a client's family about home oxygen use via nasal cannula. Which of the following statements by a family member indicates an understanding of the teaching?

"We will frequently check the top of his ears for sores."

"We can turn the oxygen up to 10 when he has trouble breathing."

"We can use petroleum jelly to keep his nares moist."

"We will need to remove the nasal cannula when he is eating."

Answer and Explanation

The Correct Answer is A

A. Frequently checking the top of the ears for sores is correct. The nasal cannula tubing can cause pressure injuries behind the ears over time. The family should check for redness or sores and use protective padding or adjust the tubing as needed.

B. Turning the oxygen up to 10 when the client has trouble breathing is incorrect. Oxygen flow rates should be adjusted only as prescribed by the provider. Increasing the flow rate without guidance can lead to complications, such as oxygen toxicity in clients with chronic respiratory conditions.

C. Using petroleum jelly to keep the nares moist is incorrect. Petroleum-based products are flammable and should not be used with oxygen therapy. Instead, a water-based lubricant should be used to prevent nasal dryness.

D. Removing the nasal cannula when eating is incorrect. Clients using a nasal cannula can continue wearing it while eating, as it allows them to receive oxygen continuously. If needed, a healthcare provider can recommend adjustments to oxygen flow during meals.

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Correct Answer is A

Explanation

A. Measure the duration of the seizure. This is the correct action. Monitoring the duration of the seizure is important for assessing its severity and deciding when to intervene medically. A seizure lasting longer than 5 minutes requires immediate intervention.

B. Lower the side rails of the bed when the seizure begins. This is not recommended. The side rails should be raised to protect the client from injury. Lowering them could increase the risk of falling out of bed.

C. Insert an oral airway into the client's mouth. This is incorrect. Inserting an airway into the mouth during a seizure can be dangerous and may result in injury to the client or the nurse. The client’s airway should be kept clear, but inserting an object into the mouth is not recommended.

D. Restrain the client's arms and legs to prevent injury. This is incorrect. Restraining the client during a seizure can cause injury to both the client and the nurse. It is better to allow the seizure to proceed naturally while ensuring the client is protected from injury (e.g., by placing a soft pillow under their head or cushioning hard surfaces around them).

A. Apply an ice pack to the affected extremity for 20 min every 2 hr. B. Massage the affected extremity every 4 hr. C. Administer aspirin for pain. D. Initiate bed rest.

Correct Answer is A

Explanation

A. Apply an ice pack to the affected extremity for 20 min every 2 hr.: Applying ice to the affected extremity can help reduce inflammation and discomfort associated with deep-vein thrombosis (DVT). This method is often recommended to decrease swelling and prevent further complications.

B. Massage the affected extremity every 4 hr.: Massage should be avoided in cases of DVT as it can dislodge the thrombus, leading to a pulmonary embolism or other life-threatening complications.

C. Administer aspirin for pain.: Aspirin is not recommended for clients on anticoagulant therapy, as it can increase the risk of bleeding. Other pain relief options should be considered that do not interact with anticoagulants.

D. Initiate bed rest.: While limited activity is necessary to prevent the risk of embolism, complete bed rest is not typically recommended. Early ambulation (when safe. is often encouraged to prevent complications like venous stasis.

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A nurse is reinforcing teaching with a client's family about home oxygen use via nasal cannula. Which of the following statements by a family member indicates an understanding of the teaching?

Nursing Test Bank

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