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 D

Explanation

A. While determining if medications can be given in generic form can be a cost-effective measure and might be beneficial for the client, it is not the most urgent action to take during the admission process. The primary focus should be on ensuring that the medications are correct, safe, and appropriate for the client’s current condition and needs.
B. Client education about the desired effects of medications is important for ensuring the client understands their treatment and can identify any side effects or issues. However, this is typically done after ensuring that the medication list is accurate and reconciled. Teaching should be part of a comprehensive plan once the medication list and dosages are confirmed.
C. Reconciliation of prescribed medication dosages with recommended dosage ranges is important for ensuring the client receives appropriate and safe dosages. However, this action is part of a broader process of medication reconciliation, which involves verifying and comparing the current list of medications against previous records and established guidelines.
D. Comparing admission prescriptions with the list of medications previously taken by the client is a crucial first step in the medication reconciliation process. This action ensures that there is no duplication, omission, or incorrect change in the medication regimen. It helps prevent potential medication errors and ensures continuity of care.

A. Initiate infusion for an IV fluid bolus. B. Administer an IV antiemetic. C. Medicate with PRN IV narcotic. D. Discourage straining on stool.

Correct Answer is C

Explanation

A. While hydration is important, it's not the most immediate concern when the client is experiencing severe pain and nausea. Addressing the pain should be the priority.
B. Antiemetics can be helpful for managing nausea and vomiting, but they may not be as effective in addressing the severe pain.
C. The client's self-reported pain level of 9 on a 0 to 10 scale indicates severe pain, which requires immediate management. IV narcotics are effective for managing severe pain and can be administered quickly to provide immediate relief. Addressing the client's pain can also help to alleviate nausea and vomiting, as pain can exacerbate these symptoms.
D. This is not relevant to the client's current symptoms of severe pain and nausea.

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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

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Correct Answer is D

Explanation

Correct Answer is C

Explanation

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