A provider is discharging a client with a prescription for home oxygen therapy. The nurse should reinforce which of the following instructions with the client and his family? (Select all that apply.)
Apply petroleum jelly around and inside the nares.
Cleanse the mask or collar with soapy water every other day.
Make sure the straps on the mask are secure but not too tight.
Post "no smoking" warning signs at home in a prominent location.
Check the tops of his ears regularly for skin breakdown.
Correct Answer : C,D,E
Apply petroleum jelly around and inside the nares:
Petroleum jelly is not recommended for use with oxygen therapy. It can be flammable and may increase the risk of fire when in contact with oxygen.
B. Cleanse the mask or collar with soapy water every other day:
While it's important to keep the oxygen equipment clean, using soapy water might not be suitable for all types of oxygen masks or collars. Specific cleaning instructions provided by the supplier or healthcare provider should be followed to ensure proper hygiene and maintenance of the equipment.
C. Make sure the straps on the mask are secure but not too tight:
Proper fitting of the oxygen mask is crucial for comfort and adequate oxygen delivery. The straps should be secure enough to hold the mask in place but not so tight as to cause discomfort or skin irritation.
D. Post "no smoking" warning signs at home in a prominent location:
Oxygen is highly combustible, and smoking near oxygen can lead to fires or explosions. It's crucial to have clear warning signs in the home to prevent smoking in areas where oxygen is used.
E. Check the tops of his ears regularly for skin breakdown:
Prolonged use of oxygen masks or nasal cannulas can cause skin breakdown, particularly around the ears where the tubing or mask straps may rest. Regular checks for any signs of skin breakdown are essential for early detection and prevention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Offer to request a prescription for an indwelling urinary catheter.
Indwelling urinary catheters come with their own set of risks and complications. It is generally not recommended to use them solely for the purpose of preventing falls unless there are other medical indications for their use. Catheters increase the risk of infection and other complications, and their use should be based on clear medical necessity.
B. Keep a night light on in the client's room.
This option directly addresses the client's concern about falling during the night. Providing a night light in the room helps to alleviate disorientation, making it safer for the client to navigate to the bathroom. It is a practical and non-invasive intervention.
C. Put the side rails up and tell the client to call for assistance to the bathroom.
While using side rails can be a fall prevention measure, it's important to consider that they are not without risks. Side rails can lead to entrapment or injury if not used appropriately. In addition, telling the client to call for assistance is good advice, but relying solely on this instruction may not address the immediate concern of disorientation in new surroundings.
D. Limit the client's fluid intake in the evening.
While limiting fluid intake in the evening might reduce the frequency of bathroom trips, it is not the most appropriate response to the client's concern. Dehydration can lead to other health issues and should not be used as the primary strategy for fall prevention.
Correct Answer is C
Explanation
A. "Client fell out of bed and cut his forehead due to sedative-induced confusion."
This option provides information about the fall and the cause but lacks specific details about the injury, location, or the client's orientation. It is not as detailed or objective as it could be.
B. "Client found lying on the floor with blood on his face. Assistive personnel forgot to put side rails up at bedtime."
This option includes information about the client's position, the presence of blood, and attributes the fall to the failure of the assistive personnel to put up side rails. While it provides some details, it introduces an element of blame and speculation. It's important to stick to factual information in documentation.
C. "Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only."
This option provides specific details about the client's position, the nature and location of the injury (laceration), and the client's orientation status. It is concise, objective, and focused on the relevant information.
D. "Client fell out of bed and received a facial laceration when his head hit the bedside table. See incident report in the medical record for further details."
This option includes information about the fall, the injury, and refers to an incident report for further details. While it provides information, it may be more appropriate to include essential details directly in the documentation rather than referring to another document for additional information.
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