A nurse is caring for a client receiving high-flow oxygen therapy via a noninvasive positive pressure ventilation (NPPV) device. What is an important nursing intervention for this client?
Assessing the client's oxygen saturation every 4 hours.
Monitoring the client's respiratory rate every 15 minutes.
Providing frequent oral care to prevent dry mouth.
Administering oxygen at a flow rate of 1-2 L/min.
The Correct Answer is C
Answer: c. Providing frequent oral care to prevent dry mouth.
Explanation: NPPV devices, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), can cause dry mouth. Providing frequent oral care, such as mouth rinses and moisturizing agents, helps alleviate discomfort and prevent oral complications.
Incorrect choices: a. Assessing the client's oxygen saturation every 4 hours is not specific to NPPV therapy and does not address the unique nursing intervention required for this intervention.
b. Monitoring the client's respiratory rate every 15 minutes may not be necessary for all clients receiving NPPV therapy and should be based on the client's condition and healthcare provider's orders.
d. Administering oxygen at a flow rate of 1-2 L/min is not appropriate for NPPV therapy, which delivers a higher flow of pressurized air to support ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: a. Ensuring the reservoir bag remains inflated at all times.
Explanation: The nurse should ensure that the reservoir bag attached to the non-rebreather mask remains inflated at all times. The inflated bag provides a reservoir of oxygen and ensures a high concentration of oxygen is delivered to the client during inhalation.
Incorrect choices: b. Adjusting the oxygen flow rate based on the client's preference is not appropriate without healthcare provider orders. The flow rate should be prescribed based on the client's oxygen needs.
c. Checking the client's oxygen saturation every 2 hours may not be necessary for all clients receiving oxygen therapy via a non-rebreather mask. The frequency of oxygen saturation monitoring should be based on the client's condition and healthcare provider's orders.
d. Encouraging the client to remove the mask during meals is not recommended unless otherwise specified by the healthcare provider. Removing the mask during meals may compromise oxygen delivery and should be avoided.
Correct Answer is A
Explanation
Answer: a. Dry nasal passages
Explanation: Prolonged use of a nasal cannula can lead to dryness and discomfort in the nasal passages due to the direct flow of oxygen. The nurse should provide humidification to prevent or alleviate dryness and nasal irritation.
Incorrect choices: b. Hypoventilation is not a common complication associated with the use of a nasal cannula, which is a low-flow oxygen delivery device.
c. Hyperoxygenation refers to an excessive supply of oxygen, which is not typically associated with nasal cannula use, as the flow rate is relatively low.
d. Increased risk of infection is not directly associated with nasal cannula use. However, proper infection control practices should be followed during oxygen therapy to minimize the risk of infection.
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