The nurse notices redness under the chin of a client who is receiving oxygen at 2 L/minute via a nasal cannula. What action should the nurse take?
Cease the use of the nasal cannula.
Reduce the flow rate to 1 L/minute.
Apply lubricant to the cannula tubing.
Attach padding around the cannula tubing.
The Correct Answer is D
Choice A rationale
Ceasing the use of the nasal cannula would interrupt the client’s oxygen therapy, which could potentially worsen their condition. Therefore, this is not the best course of action.
Choice B rationale
Reducing the flow rate to 1 L/minute may not be appropriate as the client’s oxygen needs may not be met at a lower flow rate. The redness under the chin is likely due to the friction from the cannula tubing, not the flow rate of the oxygen.
Choice C rationale
Applying lubricant to the cannula tubing may not be effective in preventing skin breakdown and could potentially cause additional discomfort or complications for the client.
Choice D rationale
Attaching padding around the cannula tubing can help reduce the friction between the tubing and the skin, which can help prevent skin breakdown. This is the most appropriate action to take in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Comparing muscle strength bilaterally is not the most important intervention in this situation. While muscle weakness can be a symptom of hyperkalemia, it is not the most immediate concern. Hyperkalemia can lead to life-threatening cardiac dysrhythmias, which is a more immediate threat to the patient’s life.
Choice B rationale
Observing the color and amount of urine can provide information about the patient’s renal function, which is important in the regulation of potassium. However, this is not the most immediate concern when a patient’s serum potassium level is dangerously high.
Choice C rationale
Determining the apical pulse rate and rhythm is the most important intervention. Hyperkalemia can cause cardiac dysrhythmias, so the nurse should immediately assess the patient’s heart rate and rhythm. The nurse should also place the patient on a cardiac monitor, if not already done, and notify the healthcare provider immediately.
Choice D rationale
Assessing the strength of deep tendon reflexes can provide information about neuromuscular function, which can be affected by hyperkalemia. However, this is not the most immediate concern. The nurse’s priority is to assess and monitor for life-threatening cardiac dysrhythmias.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
A productive cough is not a specific indicator of hypoxia. It could be a symptom of many conditions, including a common cold, flu, or other respiratory tract infections.
Choice B rationale
A respiratory rate of 28 breaths/minute is higher than the normal range (12-20 breaths/minute for adults), indicating that the patient may be trying to increase oxygen intake and eliminate carbon dioxide due to hypoxia.
Choice C rationale
An oxygen saturation of 90% on room air is lower than the normal range (95%-100%). This indicates that the patient’s blood is not carrying as much oxygen as it should, which is a sign of hypoxia.
Choice D rationale
A heart rate of 101 beats/minute is higher than the normal range (60-100 beats/minute for adults). This could be a response to hypoxia as the body tries to deliver more oxygen to the tissues.
Choice E rationale
A capillary refill of 4 seconds is slightly longer than the normal range (less than 2 seconds). While this could indicate poor peripheral circulation, it is not a specific or direct indicator of hypoxia.
Choice F rationale
A blood pressure of 145/89 mm Hg is higher than the normal range (less than 120/80 mm Hg). While hypertension could be related to many factors, it is not a specific indicator of hypoxia.
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