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.
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%.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Printing the EMR from a backup server does not resolve the immediate issue of the system lockup and may not be possible if the system is down.
Choice B reason: Identifying information as a late entry is a step to take after the system issue has been resolved and does not address the current problem.
Choice C reason: Waiting for the system to be rebooted is passive and does not actively contribute to resolving the system lockup.
Choice D reason: Notifying the information services department is the first and most proactive step to take, as they are responsible for resolving technical issues with the EMR system.
Correct Answer is C
Explanation
Choice A reason: Completing an admission assessment is typically the responsibility of a registered nurse (RN) due to the comprehensive nature of the assessment.
Choice B reason: Accessing a central venous line is usually within the scope of practice of an RN, not a PN, due to the complexity and potential complications associated with central lines.
Choice C reason: Reinforcing discharge teaching is an appropriate task for a PN, as it involves reviewing and ensuring the client understands the instructions already provided by the RN or healthcare provider.
Choice D reason: Initiating blood product infusions is generally the responsibility of an RN because of the critical nature of the task and the potential for adverse reactions.
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