A nurse is assessing a patient who is receiving oxygen therapy via venturi mask. The nurse hears a hissing sound from the mask and observes that the patient's skin color is pale. What should the nurse say to the patient?
"I'm going to check your oxygen level with this device on your finger.”.
"You need to breathe more deeply and slowly to get enough oxygen.”.
"There is a problem with your mask and I need to fix it right away.”.
"You are getting too much oxygen and I need to lower the flow rate.".
The Correct Answer is C
Choice A rationale:
The nurse should not immediately check the patient's oxygen level with a finger device because the priority is to address the hissing sound from the mask and the patient's pale skin color, which could indicate inadequate oxygen delivery.
Choice B rationale:
Instructing the patient to breathe more deeply and slowly won't address the issue of the hissing sound and the possible oxygen delivery problem. The nurse should address the equipment issue first.
Choice C rationale:
This is the correct choice. The nurse should inform the patient that there is a problem with the mask, and it needs to be fixed promptly to ensure adequate oxygen therapy.
Choice D rationale:
Lowering the flow rate may not be appropriate until the nurse has assessed and resolved the problem with the mask. It's essential to troubleshoot the equipment first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The goal of oxygen therapy is not to provide the highest fraction of inspired oxygen (FiO2) possible. This approach can be harmful because excessively high FiO2 levels can lead to oxygen toxicity and other side effects, especially in patients with certain conditions like chronic obstructive pulmonary disease (COPD).
Choice B rationale:
The goal of oxygen therapy is to use the lowest FiO2 that achieves an acceptable blood oxygen level without harmful side effects. This approach is known as titrating the oxygen therapy to the patient's needs and helps prevent potential complications associated with excessive oxygen administration.
Choice C rationale:
Maintaining a constant FiO2 regardless of the patient's breathing pattern is not the goal of oxygen therapy. In some cases, patients may require varying FiO2 levels based on their respiratory status, so it is essential to adjust the oxygen delivery accordingly.
Choice D rationale:
Delivering a fixed amount of oxygen that is independent of the patient's condition is not the goal of oxygen therapy. Oxygen therapy should be individualized and tailored to the patient's specific needs to optimize its effectiveness and safety.
Correct Answer is ["A","C","E"]
Explanation
The correct answers are choices A, C, and E.
Choice A rationale:
A Venturi mask is designed to deliver a precise concentration of oxygen and is often used in COPD, where it is important not to over-oxygenate the patient. It allows for the adjustment of oxygen concentration by changing the color-coded entrainment adapters.
Choice B rationale:
A non-rebreather mask is not typically used for clients who require a precise concentration of oxygen because it is designed to deliver high concentrations of oxygen, but without a way to precisely control the amount.
Choice C rationale:
An aerosol mask can be used with a nebulizer system to deliver specific concentrations of oxygen along with medication, which is beneficial for COPD patients who may need bronchodilators or steroids in addition to oxygen therapy.
Choice D rationale:
A simple face mask is not suitable for delivering a precise concentration of oxygen as it does not allow for the fine control needed for COPD patients. It is generally used for short-term oxygen therapy and for patients who require a moderate amount of oxygen.
Choice E rationale:
A tracheostomy collar can provide a specific concentration of oxygen when used with a tracheostomized patient and is suitable for long-term use in COPD patients who have a tracheostomy.
In summary, for a client with COPD who requires a precise concentration of oxygen, the Venturi mask, aerosol mask, and tracheostomy collar are appropriate choices as they allow for the delivery of a specific and controlled amount of oxygen.
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