A nurse is attending to a patient who is receiving a unit of packed RBCs. The patient’s vital signs at 0800 and 0815 are given.

Heart rate of 110 bpm

Complete the following sentence using the list of options.

The patient exhibits symptoms of ________

Choice A rationale

Regulating the flow rate by aligning the rate with the top of the ball inside the flow meter is a common practice in oxygen therapy. However, this action is not the most critical aspect to include when reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse.

Choice B rationale

Regulating oxygen via nasal cannula at a flow rate of no more than 6 L/min is indeed an important aspect of oxygen therapy. Oxygen delivered at higher rates using a traditional nasal cannula can dry out sinus passages and lead to nosebleeds. Nasal cannula is typically started at 2L/min and then titrated upwards to as high as 6L/min, although 2-4L/min is ideal. This delivers 25-40% FIO2, depending upon their respiratory rate, tidal volume, and amount of mouth breathing. Therefore, this action should be included when educating a newly licensed nurse about the administration of oxygen therapy.

Choice C rationale

Ensuring the reservoir bag of a partial rebreathing mask remains deflated is not a recommended practice. A partial rebreathing mask is a face mask with a reservoir bag that delivers moderate to higher concentrations of oxygen. Frequent inspection of the reservoir bag is required to ensure that it remains inflated; if it is deflated, exhaled air collects in it, which results in the patient rebreathing large amounts of exhaled carbon dioxide. Therefore, this action should not be included when educating a newly licensed nurse about the administration of oxygen therapy.

Choice D rationale

Using petroleum jelly to lubricate the patient’s nares, face, and lips is not recommended. Even though use of intranasal petroleum jelly is common, it is not recommended. The heaviness of the base does not allow normal secretion and/or absorption of fluids or medications. Vitamin E oil is a much more appropriate and equally available remedy. This lighter nonpetroleum lubricant has a natural emollient effect. Therefore, this action should not be included when educating a newly licensed nurse about the administration of oxygen therapy. Dressing Dressing Explore

Choice A rationale

The blood pressure of 114/86 mm Hg is within the normal range and does not require follow- up.

Choice B rationale

The oxygen saturation of 85% on room air is below the normal range of 95% to 100%, indicating the client may be experiencing hypoxemia, which requires follow-up.

Choice C rationale

The temperature of 38.6C (101.5° F) is slightly elevated, indicating the client may have a fever, which requires follow-up.

Choice D rationale

The heart rate of 99/min is slightly elevated, indicating the client may be experiencing tachycardia, which requires follow-up.