The nurse is caring for a client receiving oxygen therapy via a nasal cannula. Which action by the nurse is appropriate when providing oral care to the client?

Removing the nasal cannula during oral care.

Increasing the oxygen flow rate during oral care.

Applying petroleum jelly to the client's lips before oral care.

Instructing the client to breathe through the mouth during oral care.

Answer and Explanation

The Correct Answer is A

Answer: a. Removing the nasal cannula during oral care.

Explanation: To ensure effective oral care, the nurse should temporarily remove the nasal cannula while performing oral care procedures. This allows better access to the client's mouth and prevents interference with oral hygiene.

Incorrect choices: b. Increasing the oxygen flow rate during oral care is not necessary and may lead to unnecessary oxygen supplementation.

c. Applying petroleum jelly to the client's lips before oral care may be helpful for preventing dryness and chapping but is not directly related to the administration of oral care.

d. Instructing the client to breathe through the mouth during oral care is not necessary if the nasal cannula is temporarily removed to facilitate oral hygiene.

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Correct Answer is C

Explanation

Answer: c. Applying a sterile dressing over the tracheostomy site.

Explanation: Applying a sterile dressing over the tracheostomy site helps prevent infection by providing a barrier against microorganisms. It also ensures a clean environment for optimal oxygen delivery and promotes wound healing.

Incorrect choices: a. Regularly suctioning the tracheostomy tube is important for maintaining airway patency but may not directly address infection prevention or oxygen delivery.

b. Assessing the client's respiratory rate every hour is important for monitoring respiratory status but does not specifically address infection prevention or oxygen delivery.

d. Administering humidified oxygen through the tracheostomy tube may be necessary to provide moistened air to the client's lungs but does not directly address infection prevention.

A. Changing the position of the mask every 2 hours. B. Applying a protective barrier cream to the client's face. C. Padding the pressure points on the client's face with soft material. D. Encouraging the client to remove the mask intermittently for facial skin care.

Correct Answer is C

Explanation

Answer: c. Padding the pressure points on the client's face with soft material.

Explanation: Oxygen masks, especially those that exert pressure on specific areas of the face, can cause skin breakdown and pressure ulcers. Padding the pressure points with soft material helps distribute the pressure more evenly and reduces the risk of skin damage.

Incorrect choices: a. Changing the position of the mask every 2 hours is important for preventing pressure ulcers related to prolonged pressure on the skin but may not directly address the pressure points created by the mask.

b. Applying a protective barrier cream to the client's face is not specifically indicated for preventing pressure ulcers caused by oxygen masks. It is more commonly used for preventing moisture-associated skin damage.

d. Encouraging the client to remove the mask intermittently for facial skin care may compromise oxygen delivery and is not recommended unless otherwise specified by the healthcare provider.

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The nurse is caring for a client receiving oxygen therapy via a nasal cannula. Which action by the nurse is appropriate when providing oral care to the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is C

Explanation

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