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 A
Explanation
A humidifier.
Choice A rationale:
A humidifier is necessary to prevent complications in a patient receiving oxygen therapy via a tracheostomy collar. Oxygen delivered through a tracheostomy can dry out the airways and cause discomfort and potential complications. Adding humidity helps maintain airway moisture and prevents drying of the mucous membranes, reducing the risk of mucus plugs and irritation.
Choice B rationale:
A water seal is not necessary for a patient receiving oxygen therapy via a tracheostomy collar. Water seals are used in chest drainage systems to prevent air from entering the pleural space, but they are not relevant in this scenario.
Choice C rationale:
A suction catheter is used to clear secretions from the airway but is not directly related to preventing complications with oxygen therapy via a tracheostomy collar.
Choice D rationale:
A chest tube is not needed for a patient receiving oxygen therapy via a tracheostomy collar. Chest tubes are inserted to drain fluid or air from the pleural space, which is not applicable to this situation.
Correct Answer is C
Explanation
Choice A rationale:
Switching to a simple face mask is not the appropriate intervention for nasal dryness and irritation. A simple face mask covers the nose and mouth, and it may not provide enough relief for nasal dryness as the oxygen flow is still directed towards the nose.
Choice B rationale:
Increasing the flow rate of oxygen will not directly improve humidity. Nasal dryness and irritation are often caused by the lack of moisture in the delivered oxygen. Increasing the flow rate may worsen the issue.
Choice C rationale:
Assessing the patient's nares for patency and skin integrity is the appropriate intervention. Nasal dryness and irritation can be caused by inadequate humidification of the oxygen. Checking the patency of the nares and the condition of the skin can help identify any issues that may be contributing to the discomfort.
Choice D rationale:
Reassuring the patient that nasal dryness is a normal side effect is not sufficient. While nasal dryness can be a common side effect of using a nasal cannula, it is essential to address the issue and provide appropriate interventions to alleviate the discomfort and prevent complications.
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