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
Keep the reservoir bag fully inflated at all times.
Choice A rationale:
In a partial rebreather mask, the reservoir bag should be kept fully inflated at all times to ensure the delivery of the highest possible oxygen concentration during inspiration. The bag collects oxygen during expiration, and the one-way valve prevents the exhaled gases from entering the bag. This way, the patient can inhale a mixture of oxygen from the reservoir and fresh oxygen flow.
Choice B rationale:
Breathing through the mouth and exhaling through the nose is not a necessary instruction for a patient using a partial rebreather mask. It doesn't directly impact the effectiveness of oxygen delivery.
Choice C rationale:
Adjusting the elastic strap to fit snugly around the face is not specific to ensuring effective oxygen delivery. It is a general guideline for mask fitting but doesn't directly affect oxygen administration.
Choice D rationale:
Removing the mask every 15 minutes to check the skin is not necessary and can disrupt the delivery of oxygen therapy. It's essential to maintain a consistent oxygen supply to the patient's lungs, and removing the mask frequently can compromise that. Checking the skin can be done periodically without removing the mask completely.
Correct Answer is A
Explanation
Choice A rationale:
At a flow rate of 4 L/min, oxygen therapy through a nasal cannula can increase the risk of oxygen toxicity, especially if used for prolonged periods. Oxygen toxicity can cause damage to the lungs and other organs.
Choice B rationale:
Carbon dioxide retention is not a common complication at this flow rate. It may occur in patients with severe chronic obstructive pulmonary disease (COPD) at higher oxygen flow rates.
Choice C rationale:
Nasal dryness is a common but relatively minor complication of oxygen therapy via nasal cannula. It can cause discomfort but is not a severe concern.
Choice D rationale:
Fire hazard is not directly related to the use of a nasal cannula but rather to the use of oxygen in the presence of flammable materials or near open flames. It is a concern for all oxygen delivery devices, not specific to nasal cannulas.
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