The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3 L/minute, and the client's oxygen saturation level is 92%. Which intervention would the nurse implement?
Decrease the flow rate to 1 L/minute.
Place padding around the cannula tubing.
Apply lubricant to the cannula tubing.
Discontinue the use of the nasal cannula.
The Correct Answer is B
Choice A Reason: This is incorrect because decreasing the flow rate to 1 L/minute can compromise the client's oxygenation and worsen hypoxia. The client's oxygen saturation level is below the normal range of 95% to 100%.
Choice B Reason: This is correct because placing padding around the cannula tubing can prevent pressure ulcers and skin breakdown caused by friction and irritation from the tubing.
Choice C Reason: This is incorrect because applying lubricant to the cannula tubing can increase the risk of infection and inflammation of the nasal mucosa. Lubricant should be applied sparingly to the nares only if needed.
Choice D Reason: This is incorrect because discontinuing the use of the nasal cannula can endanger the client's life and cause respiratory failure. The client needs supplemental oxygen to maintain adequate oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because explaining that alternative treatment options may be helpful can be insensitive and unrealistic, as it may raise false hopes or imply that the husband's condition is not serious.
Choice B Reason: This is correct because encouraging the wife to share her feelings can help her cope with her grief and express her emotions in a supportive environment. The nurse should use active listening and empathic responses.
Choice C Reason: This is incorrect because offering reassurance that she is not alone can be dismissive and invalidating, as it may minimize her feelings or imply that she should not feel lonely.
Choice D Reason: This is incorrect because reminding her that her husband may still live a long time can be dishonest and inappropriate, as it may contradict the medical prognosis or imply that she should not prepare for his death.
Correct Answer is ["A","D","E"]
Explanation
Choice A: Lead the client in guided imagery
This is a correct choice because guided imagery is a non-pharmacological intervention that can help reduce pain and anxiety by creating a relaxing mental image for the client. Guided imagery can also lower the heart rate and blood pressure by activating the parasympathetic nervous system.
Choice B: Give a dose of 2.5 mg of Morphine
This is an incorrect choice because morphine is an opioid analgesic that can cause respiratory depression, hypotension, and bradycardia. The client's heart rate is already elevated, which could indicate inadequate pain relief or anxiety. Giving more morphine could worsen the client's condition and mask the underlying cause of the pain.
Choice C: Assist the client to walk around the room
This is an incorrect choice because walking around the room could increase the client's pain and heart rate by stimulating the sympathetic nervous system. The client has already done ambulation exercises with physical therapy at 1200, so there is no need to repeat them at 1400. The client should be allowed to rest in bed and conserve energy.
Choice D: Assess for sources of pain other than the surgical site
This is a correct choice because the nurse should always assess the client holistically and rule out any other potential causes of pain, such as infection, inflammation, or ischemia. The nurse should also check the surgical site for any signs of bleeding, hematoma, or infection. The nurse should use a comprehensive pain assessment tool that includes the location, intensity, quality, duration, frequency, and aggravating and relieving factors of the pain.
Choice E: Consult with the surgeon about the pain level
This is a correct choice because the nurse should collaborate with the surgeon and other members of the health care team to provide optimal pain management for the client. The nurse should report the client's pain score, vital signs, medication administration, and response to interventions. The surgeon may order additional tests or medications to address the cause of the pain and improve the client's comfort.
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