Nokea
After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?
- A. Discontinue the use of the nasal cannula.
- B. Apply lubricant to the cannula tubing.
- C. Place padding around the cannula tubing.
- D. Decrease the flow rate to 1 L/minute.
Correct Answer: C
Rationale: Padding prevents skin breakdown.
You may also like to solve these questions
The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?
- A. Explain that since the medication is a controlled substance, it must be taken.
- B. Credit the medication back and put it in the client's medication box.
- C. Keep the medication and see if the client will want to take it later.
- D. Have another nurse witness the disposal of the medication into the disposal container.
Correct Answer: D
Rationale: Witnessed disposal prevents misuse of controlled substances.
The nurse is planning assignments for the staff on a medical-surgical unit. Which task should the nurse assign to the practical nurse (PN)?
- A. Complete an admission assessment.
- B. Access a central venous line.
- C. Reinforce discharge teaching.
- D. Initiate blood product infusions.
Correct Answer: C
Rationale: PNs can reinforce teaching within scope.
When interviewing a client about sexuality/reproductive function, which is the best approach for the nurse to use?
- A. Get the most difficult questions over with first.
- B. Begin with questions that are less sensitive in nature.
- C. Ask questions in a vague, non-specific format.
- D. Share personal values to put the client at ease.
Correct Answer: B
Rationale: Less sensitive questions build rapport.
When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?
- A. Modify the nursing interventions to achieve the client's goals.
- B. Determine if the expected outcomes were realistic.
- C. Obtain current client data to compare with expected outcomes.
- D. Review related professional standards of care.
Correct Answer: C
Rationale: Current data assesses goal achievement.
A client with end-stage lung disease is dependent on a mechanical ventilator to sustain life. While the client's spouse is at the bedside, the client pleads in handwritten notes to have the endotracheal tube removed. The spouse tearfully agrees with the request. Which is the priority nursing intervention?
- A. Offer to contact the family's spiritual counselor to meet with the client and spouse.
- B. Discuss comfort measures with the client and family that will be available during withdrawal.
- C. Inform the healthcare provider of the client's desire to have life support withdrawn.
- D. Explain the actions that the healthcare team will follow for the removal of life support.
Correct Answer: C
Rationale: Notifying provider respects client autonomy.