A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse.
Which of the following actions should the nurse include?
Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.
Ensure the reservoir bag of a partial rebreathing mask remains deflated.
Use petroleum jelly to lubricate the patient’s nares, face, and lips.
The Correct Answer is B
Choice A rationale
Regulating the flow rate by aligning the rate with the top of the ball inside the flow meter is a common practice in oxygen therapy. However, this action is not the most critical aspect to include when reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse.
Choice B rationale
Regulating oxygen via nasal cannula at a flow rate of no more than 6 L/min is indeed an important aspect of oxygen therapy. Oxygen delivered at higher rates using a traditional nasal cannula can dry out sinus passages and lead to nosebleeds. Nasal cannula is typically started at 2L/min and then titrated upwards to as high as 6L/min, although 2-4L/min is ideal. This delivers 25-40% FIO2, depending upon their respiratory rate, tidal volume, and amount of mouth breathing. Therefore, this action should be included when educating a newly licensed nurse about the administration of oxygen therapy.
Choice C rationale
Ensuring the reservoir bag of a partial rebreathing mask remains deflated is not a recommended practice. A partial rebreathing mask is a face mask with a reservoir bag that delivers moderate to higher concentrations of oxygen. Frequent inspection of the reservoir bag is required to ensure that it remains inflated; if it is deflated, exhaled air collects in it, which results in the patient rebreathing large amounts of exhaled carbon dioxide. Therefore, this action should not be included when educating a newly licensed nurse about the administration of oxygen therapy.
Choice D rationale
Using petroleum jelly to lubricate the patient’s nares, face, and lips is not recommended. Even though use of intranasal petroleum jelly is common, it is not recommended. The heaviness of the base does not allow normal secretion and/or absorption of fluids or medications. Vitamin E oil is a much more appropriate and equally available remedy. This lighter nonpetroleum lubricant has a natural emollient effect. Therefore, this action should not be included when educating a newly licensed nurse about the administration of oxygen therapy. Dressing Dressing Explore
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While showering frequency can vary depending on the specific isolation precautions, it does not indicate understanding of the protective isolation precautions.
Choice B rationale
Informing friends and family to visit when feeling well does not indicate understanding of protective isolation precautions. Protective isolation precautions are designed to protect the patient from infections, not based on how the patient is feeling.
Choice C rationale
Taking a plane to visit grandchildren does not indicate understanding of protective isolation precautions. Travel restrictions would depend on the specific condition and doctor’s advice.
Choice D rationale
Wearing a face mask when leaving the hospital room is a common requirement in protective isolation precautions to prevent the spread of infections.
Correct Answer is B
Explanation
When giving a change-of-shift report about a client with pneumonia, the priority piece of information for the nurse to provide is the client’s breath sounds. This is because breath sounds can indicate the severity of the pneumonia and the effectiveness of the treatment. Changes in breath sounds can signal a worsening condition that requires immediate medical attention.
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