The patient with a chronic obstructive respiratory disease is receiving oxygen via a nasal cannula. The nurse plans to include which of the following interventions in the patient's care?
a. Assess nares for skin breakdown every 6 hours.
b. Check patency of the cannula every 2 hours.
c. Inspect the mouth every 6 hours.
d. Check oxygen flow every 24 hours.
A
Feedback
A The nurse caring for the patient with a nasal cannula should plan to assess the patient's nares and superior surface of both ears for skin breakdown every 6 hours.
B The nurse should check patency of the cannula every 8 hours; he or she should not need to check every 2 hours.
C The nurse does not need to check the patient's mouth in relation to the patient's use of a nasal cannula. The nurse should continue providing oral hygiene and may assess the mouth (i.e., tongue) for cyanosis, along with other assessment measures.
D Oxygen flow should be monitored continuously, not every 24 hours.
You might also like to view...
The nurse manager is explaining evidence-based practice (EBP) to the staff during a weekly meeting. Which statement should the manager use when explaining this approach to care?
1. "EBP expedites the assessment phase of the nursing process." 2. "EBP is a problem-solving approach to clinical practice questions." 3. "EBP is quicker than using the nursing process when providing patient care." 4. "EBP demonstrates an interest in furthering the development of nursing science."
Self-care measures the nurse or speech therapist should teach the client who has residual dysphagia after a stroke include (Select all that apply)
a. chewing each bite thoroughly. b. placing foods in the unaffected side of the mouth. c. sticking to only semi-liquids and very soft foods. d. turning the head to the unaffected side and checking for retained food.
Which, if any, of the following are generally considered essential defining elements of a profession?
1. Code of Ethics 2. PhD-level education 3. International endorsement 4. All of the above
A client planning to have her first baby visits the healthcare facility for a preconceptual
visit. Which instruction should the nurse give the client as part of preconceptional care? A) Eat sweets at bedtime if the client wakes up feeling hungry B) Include 400 mcg of folic acid as part of the daily diet C) Replace insulin with an oral diabetic agent D) Avoid prescription drugs once pregnancy is confirmed