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 A
Explanation
Choice A rationale
Inquiring about the frequency of falls in recent months is an important part of a functional assessment for an older adult patient reporting decreased strength in knees and handgrips. Falls can be a sign of decreased muscle strength and balance, which can be associated with aging and certain medical conditions.
Choice B rationale
Sundowning, or increased confusion and agitation in the late afternoon and evening, is a symptom often associated with dementia, not necessarily with decreased strength in knees and handgrips.
Choice C rationale
While discussing end-of-life care options is an important aspect of comprehensive patient care, it is not directly related to the patient’s reported symptoms of decreased strength.
Choice D rationale
Requesting the patient to lie as still as possible for the assessment may not provide comprehensive information about the patient’s functional mobility and strength.
Correct Answer is A
Explanation
Choice A rationale
The symptoms described - right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face - are indicative of a stroke. Immediate medical intervention is crucial in such cases. Initiating two large-bore IV catheters would allow for rapid administration of necessary medications and fluids. Reviewing the inclusion criteria for IV fibrinolytic therapy is also important, as this type of therapy can help dissolve the clot causing the stroke and restore blood flow to the brain.
Choice B rationale
While continuous observation for transient episodes of neurological dysfunction is important in the care of a patient with suspected stroke, it is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice C rationale
Elevating the head of the bed to 30 degrees can help reduce intracranial pressure in a patient with a stroke. However, this is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with certain types of stroke. However, aspirin is not typically the first line treatment in the acute phase of a stroke, especially when the type of stroke (ischemic or hemorrhagic) has not yet been determined.
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