a client is receiving oxygen therapy via a nasal cannula when providing nursing care which of the following interventions would be appropriate
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Nursing Elites

HESI LPN

Community Health HESI Practice Questions

1. When providing nursing care to a client receiving oxygen therapy via a nasal cannula, which of the following interventions would be appropriate?

Correct answer: B

Rationale: The correct answer is to inspect the nares and ears for skin breakdown. This is important because the nasal cannula can cause skin breakdown due to prolonged use and friction. Ensuring that the skin is intact helps prevent complications. Choice A is incorrect as oxygen therapy via a nasal cannula does not involve mist. Choice C is incorrect as lubricating the tips of the cannula is not a standard practice and may lead to complications. Choice D is incorrect because while cleanliness is important, maintaining sterile technique is not necessary for handling a nasal cannula in this context.

2. A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to:

Correct answer: B

Rationale: After a segmental lung resection, the priority nursing action should be to suction excessive tracheobronchial secretions. This helps in preventing airway obstruction from secretions, ensuring the patency of the airway and optimizing respiratory function. Administering pain medication can be important but addressing airway clearance takes precedence. Assisting the client to turn, deep breathe, and cough is essential for respiratory hygiene but not the first action immediately post-op. Monitoring oxygen saturation is crucial, but ensuring airway clearance is the priority to prevent complications.

3. Which facilities are capable of performing minor surgeries and some simple laboratory examinations?

Correct answer: A

Rationale: Secondary level health care facilities are equipped to perform minor surgeries and simple laboratory examinations. Intermediate level care (choice B) refers to a level of care between primary and secondary care, focusing on more complex procedures than minor surgeries. Tertiary level care (choice C) is specialized care that includes services like cardiac surgery and neurosurgery. Primary health care (choice D) is the first point of contact for individuals and is not typically equipped for minor surgeries or complex laboratory tests.

4. In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?

Correct answer: C

Rationale: These symptoms suggest autonomic dysreflexia, often triggered by bladder distention.

5. In which of the following settings would a community health nurse be less likely to be involved?

Correct answer: B

Rationale: Community health nurses are less likely to be involved in a physician's office with a focus on individual client care because their role primarily revolves around promoting and maintaining the health of populations and communities rather than providing direct care to individual clients. Options A, C, and D are more aligned with the community health nurse's role as they involve working in community-based settings, providing home-based care, and participating in community planning and advocacy.

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