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 B

Explanation

A. Administer an anti-anxiety medication is not the first action. The nurse should first assess and manage the client's environment and emotional state before resorting to medication.

B. Minimize environmental stimuli in the client's surroundings is correct. The client is experiencing anxiety, and minimizing stimuli helps to reduce environmental triggers and can immediately alleviate distress.

C. Explore behaviors that have helped to reduce the client's anxiety in the past is a good intervention but should not be the first response. The immediate priority is to reduce the anxiety by controlling the environment.

D. Explain to the client that anxiety causes physical manifestations is helpful but should occur after the immediate anxiety-reduction measures are in place. Providing this information can be part of the therapeutic process but does not address the client’s immediate distress.

A. Heart rhythm B. Urinary output C. Pain sensation D. Muscle strength

Correct Answer is A

Explanation

A. Heart rhythm: This is correct. Hypothermia, indicated by a body temperature of 32.5°C (90.5°F), can affect the cardiovascular system, potentially causing arrhythmias or even cardiac arrest. Monitoring heart rhythm is critical because of the risk of life-threatening cardiac complications associated with severe hypothermia.

B. Urinary output: While urinary output may decrease in hypothermic conditions due to vasoconstriction, it is not the priority. Cardiac function takes precedence, as severe hypothermia can lead to fatal arrhythmias.

C. Pain sensation: Although decreased pain sensation can occur in hypothermia, it is less urgent to monitor compared to the potential for life-threatening arrhythmias or cardiac arrest.

D. Muscle strength: While hypothermia can impair muscle strength, it is not the priority compared to monitoring for cardiac irregularities, which can be fatal if left unchecked.

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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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