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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect because occult blood is not visible to the naked eye. Waiting for observable blood may delay diagnosis and treatment of gastrointestinal bleeding.

Choice B Reason: This is incorrect because tarry black stool indicates upper gastrointestinal bleeding, which may not be related to the client's condition. Occult blood can be present in any color of stool.

Choice C Reason: This is correct because the nurse should obtain the specimen from the client's current bowel movement, regardless of its color or consistency. The test for occult blood detects hemoglobin in the stool, which may indicate bleeding anywhere along the gastrointestinal tract.

Choice D Reason: This is incorrect because contacting the healthcare provider before obtaining the specimen is unnecessary and may waste time. The nurse should follow the protocol for stool specimen collection and report any abnormal findings to the provider.

A. Instill 50 mL of normal saline solution into the tube and clamp the tube for one hour. B. Turn the suction off while allowing the client to rinse his mouth with cool water. C. Provide oral sponge toothettes so the client can cleanse and moisten his mouth. D. Teach the client that the oral mucosa must remain dry to prevent aspiration.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because instilling normal saline solution into the nasogastric tube can cause fluid overload, electrolyte imbalance, or aspiration. Clamping the tube for one hour can also increase the risk of aspiration and gastric distension.

Choice B Reason: This is incorrect because turning the suction off can cause gastric distension and discomfort. Rinsing the mouth with cool water can also increase the risk of aspiration if the client swallows some of the water.

Choice C Reason: This is correct because oral sponge toothettes are soft and gentle on the oral mucosa and can help moisten and cleanse the mouth without causing irritation or aspiration.

Choice D Reason: This is incorrect because teaching the client that the oral mucosa must remain dry is false and can lead to further dryness, cracking, bleeding, and infection. The oral mucosa should be kept moist and clean to prevent these complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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