Author Question: A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse ... (Read 45 times)

vicotolentino · **on:** Jun 25, 2018

A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)?

a. Apply water-soluble ointment to nares and lips.
b. Periodically turn the oxygen down or off.
c. Remove the tubing from the client's nose.
d. Turn the client every 2 hours or as needed.

Question 2

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are being met?

a. 100 of meals being eaten by the client
b. Intact skin behind the ears
c. The client understanding the need for oxygen
d. Unchanged weight for the past 3 days

ntsoane kedibone · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
Oxygen can be drying, so the UAP can apply water-soluble lubricant to the client's lips and nares. The UAP should not adjust the oxygen flow rate or remove the tubing. Turning the client is not related to comfort measures for oxygen.

Answer to Question 2

ANS: B
Oxygen tubing can cause pressure ulcers, so clients using oxygen have the nursing diagnosis of Risk for Impaired Skin Integrity. Intact skin behind the ears indicates that goals for this diagnosis are being met. Nutrition and weight are not related to using oxygen. Understanding the need for oxygen is important but would not take priority over a physical problem.