The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe? Select all that apply.

Over the cheeks.

Around the nostrils.

Across the forehead.

Bridge of the nose.

Tops of the ears.

Answer and Explanation

Correct Answer : A,B,D,E

A.   The cheeks can be affected by the nasal cannula, especially if it is not positioned properly or if it causes irritation over time.
B.   The area around the nostrils is one of the most common sites for skin damage related to nasal cannulas. Continuous contact with the cannula can cause irritation, redness, or even sores in this area.
C.   The nasal cannula itself does not typically make contact with the forehead. Therefore, skin damage across the forehead is not generally a concern related to the use of a nasal cannula.
D.   The bridge of the nose is a key area to inspect for skin damage. The nasal cannula’s prongs often rest on or near the bridge of the nose, which can lead to pressure sores, redness, or irritation in this area. Regular assessment is important to prevent and address any damage.
E.   The tops of the ears can be affected if the nasal cannula’s tubing or securing mechanism (such as behind-the-ear supports or loops) causes friction or pressure. Skin breakdown can occur in this area if the cannula is not properly adjusted or if it causes irritation.

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Correct Answer is A

Explanation

A. The walker should be adjusted to the client's height so that their elbows are slightly flexed when grasping the hand bars. This allows for proper weight-bearing and reduces strain on the shoulders and arms. Using a walker that is the correct height can help to prevent falls by providing better stability and support.
B. Removing the wheels from the walker would make it difficult for the client to use. The wheels are an important feature of a walker, as they allow the client to move more easily.
C. While demonstrating more coordinated movement may be helpful, it's not the most immediate action needed. Adjusting the height of the walker is a more important step to ensure the client's safety and comfort.
D. Encouraging the client to continue using the walker as observed may not be appropriate if the walker is not adjusted to the correct height. A properly adjusted walker is essential for safe and effective mobility.

A. Revise clinical practice guidelines. B. Engage staff in evidence based practice. C. Evaluate effectiveness of the change. D. Consult with a clinical nursing expert.

Correct Answer is C

Explanation

A. Revising clinical practice guidelines might be necessary in the long term if the new approach becomes widely accepted and proven effective. However, this action is typically part of a broader, organizational process that follows initial implementation and evaluation.
B. Engaging staff in evidence-based practice is crucial for successful implementation of the new approach. This involves educating and training staff on the new methods, ensuring they understand and support the change, and integrating the new practices into daily routines.
C. Evaluating the effectiveness of the change is a critical next step. After implementing a new approach, it is essential to assess whether it achieves the desired outcomes and improves client care. This evaluation involves monitoring and analyzing results to determine if the change is beneficial and meets the intended goals.
D. Consulting with a clinical nursing expert can be helpful for advice and guidance during the implementation process. However, this action is typically part of the initial planning and decision-making stages rather than the immediate next step after gathering evidence.

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The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is ambulating with a two wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client's elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, which action should the nurse implement?

Correct Answer is A

Explanation

The nurse implements a change in the approach to client care after gathering evidence in support of the new approach. Which action should the nurse take next?

Correct Answer is C

Explanation

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?

When assessing a client's pain, the nurse determines the location and intensity of the pain. To gather data about the quality of the pain, which action should the nurse take?