The practical nurse (PN) is completing a focused assessment on a client who is prescribed oxygen at 3 liters per minute by nasal cannula. Which assessment finding by the PN requires immediate action?
The flowmeter shows 1 liter of oxygen being delivered
There is no humidifier atached to the delivery system
The client is lying in a supine position in the bed.
The cannula is pressed snugly against the client's cheeks.
The Correct Answer is A
A. This finding requires immediate action, as it indicates that the client is not receiving the prescribed amount of oxygen, which can compromise the oxygenation and perfusion of the tissues. The PN should adjust the flowmeter to deliver 3 liters per minute of oxygen, and check for any leaks or kinks in the tubing.
The other options are not correct because:
B. The absence of a humidifier does not require immediate action, as it is not a critical component of the oxygen delivery system. A humidifier can help moisten the dry oxygen and prevent mucosal irritation, but it is not essential for oxygenation.
CThe supine position does not require immediate action, as it is not a contraindication for oxygen therapy. The client may prefer this position for comfort or rest, and it does not affect the oxygen delivery or uptake.
D . The snug fit of the cannula does not require immediate action, as it is not a problem for oxygen therapy. The cannula should fit snugly against the client's cheeks to prevent dislodgment or slippage, and it does not interfere with the oxygen flow or diffusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Assigning the newly hired unlicensed assistive personnel (UAP) to clients who require the least complex level of care is not the best approach to ensure adequate care for all clients. It may limit the UAP's opportunities for learning and growth and may not fully utilize their skills.
Choice B rationale:
Asking the most experienced UAP to partner with the newly hired UAP is a reasonable approach, but it may not provide a comprehensive solution. It can be beneficial for mentorship and guidance, but it may not address all the clients' needs efficiently.
Choice C rationale:
Reviewing the UAP's skills checklist and experience with the person who hired the UAP is an important step in assessing competency. However, it alone may not ensure adequate care for all clients. Competency assessment should be ongoing and include direct observation of care delivery.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should instruct the client to sleep with an extra pillow under their head. This position, known as the semi-Fowler's position, elevates the upper body and head, which can help reduce shortness of breath and difficulty breathing while lying down at night. Propranolol, a non-selective beta-blocker, can cause bronchoconstriction in some individuals, especially those with a history of respiratory issues. Elevating the head can assist in improving lung expansion and reducing the sensation of breathlessness.
Choice B rationale:
Sleeping on their left side would not be the best option in this case. While sleeping on the left side is often recommended for individuals with certain cardiac conditions to improve blood flow and reduce pressure on the heart, it may not be as effective for alleviating the respiratory symptoms caused by propranolol. Elevating the head is a more appropriate intervention in this scenario.
Choice C rationale:
Sleeping on their right side is not the ideal choice either. While it can have benefits for individuals with certain cardiac conditions, it does not address the specific respiratory symptoms reported by the client. Elevating the head is a more targeted intervention to alleviate breathlessness associated with propranolol.
Choice D rationale:
Sleeping on their back may worsen the client's symptoms. Lying flat on the back can lead to increased pressure on the diaphragm, making it more challenging to breathe for individuals experiencing shortness of breath. Therefore, it is not the recommended position for this client.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.