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 B
Explanation
A. "Provide informational updates to members of the media" is incorrect. This task typically falls under the responsibility of the hospital’s public relations or communications team. Nurses do not usually handle media updates in the context of mass casualty events.
B. "Assist in discharging stable clients to home" is correct. During a mass casualty event, it is important to make room for incoming patients. Discharging stable patients helps free up beds and resources for those who need immediate care.
C. "Delegate tasks to emergency health care specialists" is incorrect. While nurses may delegate some tasks, the nurse’s primary responsibility in this scenario would be managing care within the medical-surgical unit, not directing emergency health care specialists.
D. "Determine the acuity and number of casualties arriving at the facility" is incorrect. This task is generally managed by triage teams or emergency management staff who assess incoming patients at the point of injury or arrival at the facility.
Correct Answer is B
Explanation
A. Removing personal protective equipment (PPE. after leaving the room is incorrect because it should always be done before leaving the client's room to ensure the nurse does not accidentally spread the infection. Proper removal of PPE is crucial to preventing transmission.
B. Wearing a gown when assisting the client with personal hygiene is correct. MRSA is typically spread through direct contact, so wearing a gown when providing personal care (e.g., assisting with hygiene. helps prevent the spread of MRSA. Additionally, gloves and other PPE should also be worn.
C. Negative air pressure is typically required for airborne precautions, such as for clients with tuberculosis, but not for MRSA, which is transmitted via contact. Therefore, this is not necessary for MRSA care.
D. Restricting the client's visitors is not necessary unless the client has an infection that requires isolation precautions beyond what is standard for MRSA. MRSA can be controlled with contact precautions, and visitor restrictions are generally not part of standard MRSA isolation.
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