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 D
Explanation
Choice A Reason: Massaging the injection site can cause bruising and bleeding, and is not recommended for subcutaneous heparin injections.
Choice B Reason: Rotating injections between different body sites can increase the risk of hematoma formation and skin irritation, and is not advised for subcutaneous heparin injections.
Choice C Reason: Expelling the air in the prefilled syringe can result in a loss of medication dose, and is not necessary for subcutaneous heparin injections.
Choice D Reason: Injecting in the abdominal area at least 2 inches from the umbilicus is the correct technique for subcutaneous heparin injections, as it reduces the risk of injury to blood vessels and nerves, and ensures consistent absorption of the medication.
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because palpating the suprapubic region for distention can be inaccurate and unreliable, as it can be affected by factors such as obesity, abdominal muscle tone, and bowel gas.
Choice B Reason: This is correct because scanning the client's bladder after voiding can measure the post-void residual urine volume, which indicates the amount of urine left in the bladder after urination. A high post-void residual urine volume can indicate urinary retention.
Choice C Reason: This is incorrect because reviewing the chart for number of voids over last 24 hours can provide information about the frequency of urination, but not the amount or completeness of urination.
Choice D Reason: This is incorrect because evaluating the client for urinary incontinence can assess the involuntary loss of urine, but not the ability to empty the bladder completely.
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