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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Instruct the family about withdrawal symptoms. While educating the family about withdrawal symptoms is important for support and understanding, it is not the best initial action when the
client is experiencing severe agitation and tremors. Safety measures should be prioritized.

B. Initiate seizure precautions. Severe agitation and tremors can be signs of benzodiazepine withdrawal, which may progress to seizures. Initiating seizure precautions, such as ensuring a
safe environment, padding side rails, and having emergency medications and equipment readily available, is the priority to prevent injury.
C. Obtain a serum drug screen. While obtaining a serum drug screen may be necessary to confirm benzodiazepine withdrawal, it is not the immediate action needed to address the client's current symptoms and prevent potential harm.
D. Administer naloxone per PRN protocol. Naloxone is an opioid antagonist used to reverse opioid overdose and is not indicated for benzodiazepine withdrawal. Administering naloxone would not be appropriate or effective in this situation.

A. Assist the client with clarifying values about end-of-life care options. B. Ask the client how often episodes of sundowning are experienced. C. Request to have the client lie as still as possible for the assessment. D. Question the client about the frequency of falls in recent months.

Correct Answer is D

Explanation

A. This action pertains more to discussions about advance care planning and end-of-life preferences, which may be important but are not directly related to assessing the client's functional status.

B. Episodes of sundowning are associated with changes in behavior, confusion, and agitation in some individuals with dementia, particularly in the late afternoon or evening. While important to assess in certain contexts, it is not directly related to evaluating the client's physical strength and mobility.

C. Asking the client to lie still does not provide information about their functional status or ability to perform activities of daily living.

D. This is the most appropriate action because it directly addresses the client's reported decreased strength and assesses the impact on their functional ability. Falls are a common consequence of reduced strength and mobility in older adults and can provide valuable information about the client's current physical function and safety.

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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?

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Naxlex Comprehensive Predictor Exams

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