After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?

Discontinue the use of the nasal cannula.

Apply lubricant to the cannula tubing.

Place padding around the cannula tubing.

Decrease the flow rate to 1 L/minute.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. Place padding around the cannula tubing.

Choice A rationale:

Discontinuing the use of the nasal cannula is not appropriate because the client still needs supplemental oxygen to maintain adequate oxygen saturation levels.

Choice B rationale:

Applying lubricant to the cannula tubing might help reduce friction but does not address the pressure that is causing the red mark.

Choice C rationale:

Placing padding around the cannula tubing helps to alleviate the pressure on the skin, which can prevent further irritation and allow the red mark to heal.

Choice D rationale:

Decreasing the flow rate to 1 L/minute could compromise the client’s oxygenation status, as the current flow rate is necessary to maintain an oxygen saturation level of 94%.

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Correct Answer is D

Explanation

Choice A reason: While the client's medical history and admission assessment provide valuable information, they do not directly measure the current pain experience.

Choice B reason: Vital signs can indicate pain but are not a definitive measure of pain severity as they can be influenced by other factors.

Choice C reason: The frequency of analgesic administration may suggest the level of pain control but does not measure the current pain intensity experienced by the client.

Choice D reason: Asking the client to describe the intensity of the pain is the most direct and effective way to assess pain severity. Pain is subjective, and the client's self-report is considered the gold standard for pain assessment.

A. Leave the dressing off until consulting with the healthcare provider. B. Replace the gauze with a transparent dressing. C. Increase the frequency of the dressing changes. D. Apply a hydrocolloid gel dressing.

Correct Answer is D

Explanation

Choice A reason: Leaving the dressing off is not advisable as it can expose the wound to potential infection and delay healing.

Choice B reason: A transparent dressing may not be the best choice for a stage 3 pressure injury with significant granulation tissue.

Choice C reason: Increasing the frequency of dressing changes without specific orders may not be necessary and could disrupt the healing process.

Choice D reason: A hydrocolloid gel dressing is appropriate for a stage 3 pressure injury as it maintains a moist environment, which is conducive to wound healing and granulation.

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After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

Correct Answer is D

Explanation

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is planning assignments for the staff on a medical-surgical unit. Which task should the nurse assign to the practical nurse (PN)?

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