NUR 518: Clinical Essentials | 162 ACTUAL QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS AND RATIONALE

NUR 518: Clinical Essentials | 162 ACTUAL QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS AND RATIONALE 1. When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to help maintain good skin integrity? A. Frequently applying moisturizing lotion to facial areas that come into contact with the cannula. B. Removing the cannula every 2 hours for no longer than 10 minutes. C. Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift. D. Instructing the patient to inform staff of any problems with facial dryness or cracking. - ANSWER C. Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift. Rationale: Frequent assessment is a priority and will help the nurse identify early signs of skin breakdown. Although applying lotion is appropriate, this option is not the best way to maintain good skin integrity. It may not be appropriate to remove the cannula in a patient for whom oxygen therapy has been ordered. The patient may be unaware of facial skin areas that are dry or cracking. 2. When caring for a patient who is receiving oxygen by simple face mask, which action ensures that the rate of oxygen being delivered is appropriate? A. Frequently asking the patient how he or she is breathing. B. Ensuring that the oxygen tubing is pulled tight, with little or no slack. C. Securing the oxygen tubing to the patient's clothing to prevent tugging. D. Assessing for proper placement of the mask on the patient's face. - ANSWER D. Assessing for proper placement of the mask on the patient's face. Rationale: Monitoring placement of the cannula tips helps ensure that the patient receives the oxygen prescribed. Asking the patient if he or she is having trouble breathing does not address oxygen delivery. Oxygen tubing should not be pulled tight. There should be enough slack in the tubing to allow the patient to turn his or her head comfortably. Securing the oxygen tubing to keep the patient from pulling out the cannula does not address oxygen delivery. When caring for a patient for whom oxygen by nonrebreathing mask has been ordered, which action ensures appropriate oxygen delivery?