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 C
Explanation
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%.
Correct Answer is D
Explanation
Choice A reason: Dizziness is not typically associated with perineal care and is not relevant to the instructions.
Choice B reason: Advising to keep the pubic area shaved is not a standard part of perineal care instructions and is a personal choice.
Choice C reason: The statement about not retracting the foreskin is incorrect; the foreskin should be retracted gently for cleaning and then returned to its normal position to prevent infection.
Choice D reason: It is important to inform the caregiver that an erection may occur as a natural reflex during perineal care, and it does not indicate any sexual intent. This helps prepare the caregiver to handle the situation professionally.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.