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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "If I were you, I would contact your spiritual director.": While this may be a helpful suggestion for the client, it can come across as dismissive of the client’s personal beliefs and decision-making. The nurse should respect the client’s autonomy in making healthcare decisions.
B. "I'm sure that everything will be all right, regardless of your decision.": This statement may be dismissive of the client's concerns and the seriousness of their medical decision. It also minimizes the importance of the client’s decision, which should be respected.
C. "Making this decision is wrong.": This response is judgmental and violates the client’s autonomy. The nurse should avoid imposing personal beliefs and instead support the client’s choices.
D. "You have a right to change your mind.": This is the best response, as it acknowledges the client’s autonomy and the possibility that the client may reconsider their decision in the future. It provides a nonjudgmental and supportive statement that empowers the client.
Correct Answer is D
Explanation
A. Taking ferrous sulfate on an empty stomach can increase absorption but often causes nausea and gastrointestinal upset. Clients are usually advised to take it with a small amount of food if stomach upset occurs.
B. Drinking more milk does not prevent constipation and can actually decrease the absorption of iron due to calcium content. Adequate fluids and fiber are recommended instead to manage constipation.
C. Black stools are a common and expected side effect of ferrous sulfate due to iron content. Reporting them is not necessary unless accompanied by other concerning symptoms like bleeding or abdominal pain.
D. Mixing ferrous sulfate elixir with a full glass of water helps dilute the medication, reducing irritation to the gastrointestinal tract. It also ensures proper dosing and facilitates easier swallowing of the liquid medication.
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