The nurse is caring for a client receiving oxygen therapy via a simple face mask. Which nursing intervention is important to prevent skin breakdown?
Changing the position of the mask every 2 hours.
Applying a protective barrier cream to the client's face.
Padding the pressure points on the client's face with soft material.
Encouraging the client to remove the mask intermittently for facial skin care.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is C
Explanation
Answer: c. Client reporting nasal dryness and discomfort.
Explanation: The client reporting nasal dryness and discomfort indicates inadequate humidification of the oxygen. The nurse should assess and adjust the oxygen flow rate or consider providing humidified oxygen to alleviate the client's discomfort.
Incorrect choices: a. An oxygen saturation of 98% indicates adequate oxygenation and does not necessitate an adjustment in the oxygen flow rate.
b. A respiratory rate of 16 breaths per minute within the normal range does not indicate a need for adjustment of the oxygen flow rate.
d. An oxygen flow rate set at 4 L/min may be appropriate for a Venturi mask, depending on the prescribed oxygen concentration and the client's needs.
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