The nurse observes erythema under the chin of a client receiving oxygen at 2 L/minute per nasal cannula. Which intervention should the nurse implement?
A Place padding around the cannula tubing.
B Decrease the flow rate to 1 L/minute.
C Apply lubricant to the cannula tubing.
D Discontinue the use of the nasal cannula.
The Correct Answer is A
A. Placing padding around the cannula tubing is the appropriate intervention to address the erythema under the chin. This padding can help alleviate pressure and reduce skin irritation caused by the tubing. It's a proactive measure to prevent further discomfort or skin breakdown.
B. Decreasing the flow rate to 1 L/minute might not address the issue of pressure-related erythema, and it could compromise the client's oxygenation if not clinically indicated.
C. Applying lubricant to the tubing may not effectively reduce pressure or irritation caused by the tubing under the chin.
D. Discontinuing the use of the nasal cannula should be reserved for situations where it is medically necessary or if an alternative oxygen delivery method is available.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer aspirin to prevent further clot formation and platelet clumping. While aspirin may be indicated in the treatment of ischemic stroke, it is not the immediate priority. The client requires further assessment and diagnostic evaluation before initiating specific treatments.
B. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment.
Positioning the client is important for maintaining airway patency, but it is not the priority when assessing and managing acute stroke. Immediate interventions to address potential thrombolytic therapy take precedence.
C. Begin continuous observation for transient episodes of neurologic dysfunction. Continuous observation is important for monitoring the client's neurological status, but it is not the first action to take. The client requires urgent diagnostic imaging to confirm the diagnosis and
determine eligibility for thrombolytic therapy.
D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. This is the priority action. IV access is crucial for administering medications and fluids, and reviewing the inclusion criteria for IV fibrinolytic therapy is essential to determine if the client meets the
criteria for this time-sensitive intervention.
Correct Answer is D
Explanation
A. Plan to observe the secured IV site after the insertion procedure.
This is a proactive step, but it does not address the immediate need to correct the new nurse’s choice of dressing.
B. Remind the nurse to tape the gauze dressing securely in place.
While securing the dressing is important, it is not the best practice to use a gauze dressing for IV sites as it obscures the view of the insertion site.
C. Confirm that the nurse has gathered the necessary supplies.
Confirming supplies is important, but this does not address the incorrect dressing choice.
D. Instruct the nurse to use a transparent dressing over the site.
This is the correct answer because a transparent dressing allows for continuous visual inspection of the IV site for signs of infection or infiltration, which is crucial for patient safety.
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