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. Tinnitus with ear pain: While tinnitus can be a side effect of some medications, it is not associated with Stevens-Johnson syndrome (SJS). This symptom is more common with other medications or conditions, like aspirin or certain antibiotics, but not allopurinol.
B. Diplopia: Diplopia (double vision) is not a common sign of Stevens-Johnson syndrome. This symptom could be related to other conditions but is not characteristic of SJS.
C. Hyperreflexia: Hyperreflexia is not a typical manifestation of Stevens-Johnson syndrome. While neurological symptoms may sometimes occur, they are not central to the diagnosis of SJS.
D. Skin rash with fever: A skin rash with fever is a classic early sign of Stevens-Johnson syndrome. It is a potentially life-threatening reaction to certain medications, including allopurinol, and requires immediate medical attention. The rash often begins with a mild erythema, which may progress to blistering and sloughing of the skin.
Correct Answer is A
Explanation
A. Encourage the client to be assertive is correct. Encouraging assertiveness is important for a client with dependent personality disorder (DPD., as they often have difficulty making decisions or taking initiative. Teaching the client to express their needs, opinions, and desires is a key part of treatment and helps promote independence.
B. Maintain a verbal no-harm contract with the client is incorrect. While maintaining a no-harm contract may be appropriate for clients at risk for self-harm, this is not specific to dependent personality disorder. The main goal is to promote independence and healthy decision-making, not just ensuring safety.
C. Limit the client's social interactions is incorrect. In fact, encouraging healthy social interactions and gradual independence from others is often an important part of treatment for DPD. Limiting interactions could reinforce dependency and hinder progress.
D. Assume responsibility for making the client's decisions is incorrect. The nurse should encourage the client to make their own decisions and foster independence, rather than taking over their decisions, which could worsen the dependent behaviors.
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