Oxygen at 5 L/minute per nasal cannula is being administered to a 10-year-old child with pneumonia. When planning care for this child, which principle of oxygen administration should the nurse consider?

Oxygen is less toxic when it is humidified with a hydration source.

Avoid administration of oxygen at high levels for extended periods.

Increase oxygen rate during sleep to compensate for slower respiratory rate.

Taking a sedative at bedtime slows respiratory rate, which decreases oxygen needs.

Answer and Explanation

The Correct Answer is B

A.   Oxygen is less toxic when it is humidified with a hydration source. While humidification can prevent drying of the respiratory mucosa, it does not directly relate to the principle of avoiding high levels of oxygen for extended periods.
B.   Avoid administration of oxygen at high levels for extended periods. This is the correct principle. Prolonged exposure to high levels of oxygen can lead to oxygen toxicity, which can cause lung damage. Oxygen therapy should be titrated to maintain adequate oxygenation without exposing the patient to excessive oxygen levels.
C.   Increase oxygen rate during sleep to compensate for slower respiratory rate. This statement is incorrect. Oxygen therapy should be adjusted based on the patient's oxygen saturation levels and respiratory status, not solely on sleep patterns.
D.   Taking a sedative at bedtime slows respiratory rate, which decreases oxygen needs. While sedatives can depress respiratory rate, leading to decreased oxygen needs, this is not a general principle of oxygen administration. Oxygen therapy should be based on the patient's oxygenation needs rather than medications they are taking.

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Correct Answer is B

Explanation

A. Collaborating with a science teacher to prepare a health lesson may be beneficial for health education but does not directly address secondary prevention. Secondary prevention involves early detection and intervention to prevent the progression of disease or injury.

B. Initiating a hearing and vision screening program for first graders is an example of secondary prevention. This action aims to detect any hearing or vision problems early, allowing for timely intervention and management to prevent further complications or difficulties in learning and
development.

C. Preparing a presentation on how to prevent the spread of lice may be important for promoting hygiene and preventing infestations, but it falls more under the category of health education and primary prevention rather than secondary prevention.

D. Observing a person with type 1 diabetes mellitus self-administer a dose of insulin may be related to health education or management of a chronic condition, but it does not directly address secondary prevention for school-aged children.

A. Encourage mobilization to prevent pulmonary embolism. B. Measure each calf's girth to evaluate edema in the affected leg. C. Observe for bleeding side effects related to heparin therapy. D. Assess blood pressure and heart rate at least every 4 hours.

Correct Answer is C

Explanation

A. Encourage mobilization to prevent pulmonary embolism.
While mobilization can be important in preventing further DVT development, initial bed rest is often recommended to avoid dislodging the clot. Mobilization should be carefully managed based on the provider's recommendations.

B. Measure each calf's girth to evaluate edema in the affected leg.
Measuring calf girth is useful for monitoring the extent of the DVT, but it is not the most critical intervention compared to monitoring for complications of heparin therapy.

C. Observe for bleeding side effects related to heparin therapy.
This is the correct intervention. Heparin is an anticoagulant, and monitoring for signs of bleeding (such as in the gums, urine, stool, and bruising) is crucial to prevent serious complications.

D. Assess blood pressure and heart rate at least every 4 hours.
While important, frequent monitoring of vital signs is secondary to the need to vigilantly observe for bleeding, which is a direct and significant risk of heparin therapy.

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Oxygen at 5 L/minute per nasal cannula is being administered to a 10-year-old child with pneumonia. When planning care for this child, which principle of oxygen administration should the nurse consider?

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Naxlex Comprehensive Predictor Exams

Which action should the school nurse implement to provide secondary prevention for school- aged children?

Correct Answer is B

Explanation

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?

Correct Answer is C

Explanation

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