A client is in the hospital with a medical diagnosis of viral pneumonia. They are receiving oxygen through a simple face mask. The nurse ensures that the mask fits snugly over the client’s face for which reason?

To prevent mask movement and consequent skin breakdown

To help the patient feel secure

To maintain carbon dioxide retention

To aid in maintaining expected oxygen delivery

Answer and Explanation

The Correct Answer is D

Simple face masks act as a reservoir for supplemental oxygen, increasing the fractional inspired oxygen (FiO2) concentration above atmospheric levels. In viral pneumonia, inflammation and exudate within the interstitial spaces impair the diffusion of gases across the alveolar-capillary membrane. A secure fit is necessary to prevent the entrainment of ambient room air, which would dilute the oxygen concentration and diminish the therapeutic efficacy of the delivery system.

Rationale for correct answer

4. Ensuring a snug fit prevents the leakage of oxygen and the unintentional inhalation of room air around the edges of the mask. This maintenance of the seal ensures that the client receives the prescribed concentration of oxygen required to manage the hypoxemia caused by pneumonia. It is essential for consistent clinical outcomes.

Rationale for incorrect answers

1. While preventing movement can reduce friction, a “snug” fit that is too tight can actually increase the risk of pressure injuries over the bridge of the nose and cheeks. The primary reason for a secure fit relates to the gas concentration rather than the integrity of the integumentary system. Skin care is a separate nursing priority.

2. Many patients find a tight-fitting mask to be a source of anxiety or claustrophobia rather than security. The psychological comfort of the patient is not the scientific justification for the physical fit of an oxygen delivery device. Clinical effectiveness takes precedence over the subjective feeling of mask tightness.

3. The design of a simple mask includes exhalation ports to allow for the clearance of carbon dioxide. The goal of oxygen therapy is to improve oxygenation, not to promote the retention of CO2, which could lead to respiratory acidosis. Retention of waste gases is a complication to be avoided, not a goal.

Test-taking strategy

Identify the Primary Goal: The goal of any oxygen mask is to deliver the correct concentration of oxygen to the lungs.
Analyze the Impact of Air: Room air is only 21% oxygen. If the mask is loose, the patient breathes in room air, which dilutes the 40% to 60% oxygen coming from the mask.
Eliminate Physiological Errors: Rule out 3 immediately; the nurse never wants to “maintain” CO2 retention in a pneumonia patient.
Focus on Efficacy: Choice 4 is the most “scientific” and “results-oriented” answer, focusing on the accuracy of the medical intervention.

Take home points

A simple face mask requires a minimum flow rate of 5 to 6 L/min to prevent the rebreathing of carbon dioxide.
Viral pneumonia can cause ventilation-perfusion mismatching, necessitating supplemental oxygen to maintain saturation above 92%.
The nurse must assess the skin under the mask and over the ears every 2 to 4 hours for signs of pressure.
Simple masks can deliver an FiO2 of 35% to 50% depending on the flow rate and the patient's inspiratory demand.

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Free Nursing Study Resources

Correct Answer is G,B,F,D,E,C,A,H

Explanation

1. Perform hand hygiene (Step 7)
Hand hygiene reduces the risk of introducing pathogens into the airway and prevents cross-contamination. It is always the first step before any invasive procedure.
2. Assist client to semi-Fowler’s or high Fowler’s position, if able (Step 2)
Upright positioning promotes lung expansion, improves oxygenation, and makes insertion of the catheter easier by aligning the airway.
3. Apply sterile gloves (Step 6)
Sterile gloves maintain asepsis during suctioning, which is a sterile procedure. This protects both the patient and nurse from infection.
4. Have client take deep breaths (Step 4)
Deep breathing increases oxygen reserves and reduces the risk of hypoxia during suctioning, since suctioning temporarily interrupts airflow.
5. Lubricate catheter with water-soluble lubricant (Step 5)
Lubrication minimizes trauma to the nasal mucosa and facilitates smooth passage of the catheter through the nares.
6. Advance catheter through nares and into trachea (Step 3)
The catheter is gently inserted until resistance or coughing indicates entry into the trachea. This ensures secretions are accessed at the source.
7. Apply suction (Step 1)
Suction is applied while withdrawing the catheter, not during insertion, to avoid mucosal damage and hypoxia. Suction removes secretions effectively.
8. Withdraw catheter (Step 8)
The catheter is withdrawn while rotating to maximize secretion removal. This completes the suctioning cycle safely.

Test-taking strategy

Standardize the start: Nearly every nursing procedure begins with hand hygiene (7).
Prioritize preparation: You must position the patient (2) and prepare the sterile field/gloves (6) before touching the patient or equipment.
Avoid trauma: Always lubricate (5) before you insert (3).
Apply the safety rule: You must hyperoxygenate (4) before you suction, and you must never apply suction (1) while pushing the tube in; it only happens during withdrawal (8).

Take home points

Water-soluble lubricant is mandatory to prevent lipid pneumonia and facilitate smooth passage through the nares.
Semi-Fowler's or high Fowler's position helps the patient hyperventilate and facilitates the anatomical passage of the catheter.

A. Breathe in through the nose. B. Inhale two sprays with one breath. C. Hold the breath for 5 to 10 seconds after inspiration. D. Exhale quickly through an open mouth.

Correct Answer is C

Explanation

Metered-dose inhalers (MDIs) are pressurized canisters that deliver a precise dose of aerosolized medication directly to the lower respiratory tract. The efficacy of the therapy depends on the deposition of the drug into the bronchioles rather than the oropharyngeal cavity. Proper coordination of actuation and inhalation ensures that the medication bypasses the upper airway and reaches the targeted receptors for maximum therapeutic effect.

Rationale for correct answer

3. Holding the breath for 5 to 10 seconds allows the medication particles to settle onto the respiratory mucosa through sedimentation. This pause prevents the immediate exhalation of the drug and ensures the active ingredients reach the smaller airways. It is a critical step for maximizing drug absorption.

Rationale for incorrect answers

1. The client must breathe in through the mouth to ensure a direct and unobstructed path for the aerosol to enter the trachea. Breathing through the nose acts as a filter and traps the majority of the medication in the nasal passages. Mouth breathing is essential for lower airway delivery.

2. Patients should only inhale one spray per breath to ensure the medication is properly distributed and the dosage is accurate. Inhaling two sprays simultaneously increases the likelihood of the drug hitting the back of the throat and being swallowed. Most prescriptions specify a waiting period of 1 minute between puffs.

4. Exhaling quickly prevents the medication from reaching the distal alveoli and staying there long enough to work. The correct technique involves a slow, controlled exhalation through pursed lips after the breath-hold. Quick exhalation significantly reduces the amount of medication that remains in the lungs.

Test-taking strategy

Visualize the goal: The goal of an inhaler is to get medicine down deep and make it stay there.
Evaluate the options for “deep” and “stay”:
- Rule out 1 (Nose) because it filters out the medicine.
- Rule out 4 (Quick exhale) because it blows the medicine back out.
- Rule out 2 (Two sprays) because it causes “clumping” in the throat.
Select the most logical retention method: Holding the breath (Option 3) is the only action listed that helps the medicine stay in the lungs to be absorbed.
Focus on timing: The 5 to 10 second hold is a classic educational benchmark for MDI training.

Take home points

Using a spacer or holding chamber can significantly improve the delivery of medication to the lungs for patients with poor coordination.
Patients should wait 1 to 2 minutes between puffs of the same medication to allow the first dose to begin bronchodilation.

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A client is in the hospital with a medical diagnosis of viral pneumonia. They are receiving oxygen through a simple face mask. The nurse ensures that the mask fits snugly over the client’s face for which reason?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to perform nasotracheal suctioning on a client. Arrange the steps in order.

Correct Answer is G,B,F,D,E,C,A,H

Explanation

A nurse is educating a client about inhalers. Effective use of a metered-dose inhaler requires that the client accomplish which action?

Correct Answer is C

Explanation

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