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 ["6.8"]
Explanation
Step 1: Convert the client’s weight from lbs to kg. 1 kg is approximately 2.2 lbs. So, 198 lbs ÷
2.2 = 90 kg (rounded to the nearest whole number).
Step 2: Calculate the total mcg of Dopamine needed per minute. The prescription is for 2 mcg/kg/minute. So, 90 kg × 2 mcg/kg/minute = 180 mcg/minute.
Step 3: Convert the total mcg of Dopamine in the bag to mcg/mL. The bag contains 400 mg of Dopamine in 250 mL. 1 mg is equal to 1000 mcg. So, 400 mg × 1000 = 400,000 mcg. Therefore, the concentration is 400,000 mcg ÷ 250 mL = 1600 mcg/mL.
Step 4: Calculate the mL of Dopamine needed per minute. So, 180 mcg/minute ÷ 1600 mcg/mL
= 0.1125 mL/minute.
Step 5: Convert mL/minute to mL/hour. There are 60 minutes in an hour. So, 0.1125 mL/minute × 60 = 6.75 mL/hour. The IV pump should be set to deliver 6.8 mL/hour (rounded to the nearest tenth).
Correct Answer is C
Explanation
Choice A rationale
While obtaining a serum drug screen might be helpful in confirming the presence of benzodiazepines or other substances, it is not the most immediate concern in a client experiencing severe agitation and tremors due to withdrawal.
Choice B rationale
Naloxone is an opioid antagonist and would not be effective in managing withdrawal symptoms from benzodiazepines.
Choice C rationale
Seizure precautions should be initiated as withdrawal from benzodiazepines can lead to severe withdrawal symptoms, including seizures. Therefore, ensuring the safety of the client by initiating seizure precautions is the best initial nursing action.
Choice D rationale
While education is an important part of nursing care, in this situation, the client’s immediate physical needs take precedence.
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