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 D

Explanation

A: Using a different sphygmomanometer would not address the underlying cause of the spasms, which is likely not related to the equipment itself.
B: Taking the blood pressure in the other arm may avoid the spasms temporarily, but it does not address the potential underlying medical issue causing the spasms.
C: Administering an antianxiety medication is not indicated as the spasms are not necessarily related to anxiety; they could be a sign of a physiological condition.
D: Reviewing the client's serum calcium level is the most appropriate action. The spasms described are indicative of Trousseau's sign, which is associated with hypocalcemia. Hypocalcemia can cause increased neuromuscular excitability, leading to spasms. It is important to identify and treat the underlying cause of the spasms, which in this case could be a calcium deficiency.

Correct Answer is ["100"]

Explanation

Total volume of the infusion: 50 mL (saline bag)
Infusion time: 30 minutes = 0.5 hours (convert minutes to hours)
We don't need the concentration of gentamicin for this calculation because we're only interested in the total volume delivered per hour.
Flow rate: Since all the medication is delivered within the infusion time, the flow rate is equal to the total volume divided by the infusion time.

Flow rate (mL/hour) = Total volume (mL) / Infusion time (hours)

Flow rate = 50 mL / 0.5 hours Flow rate = 100.0 mL/hour

Therefore, the nurse should set the pump to deliver 100.0 mL/hour to infuse the 60 mg of gentamicin over 30 minutes.

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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

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

Correct Answer is D

Explanation

Correct Answer is ["100"]

Explanation

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