A nurse is caring for a client who has been receiving oxygen via simple face mask for 6 hours. Which of the following assessment findings indicates that oxygen therapy has been effective?

The correct answer is choice B: Diagnosis.

Choice A rationale:

Assessment is the first phase of the nursing process where the nurse collects comprehensive data pertinent to the patient’s health or the situation. In the scenario, the nurse has already gathered data about the client’s respiratory status, indicating that the assessment phase has been completed.

Choice B rationale:

Diagnosis is the phase where the nurse analyzes the assessment data to determine the issues, which in this case is ‘impaired gas exchange.’ This is the phase where the nurse identifies that the client’s symptoms (dyspnea and cyanosis) and elevated respiratory rate are indicative of impaired gas exchange.

Choice C rationale:

Planning is the phase where the nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. It follows the diagnosis and involves setting priorities, but in the given scenario, the nurse is still at the stage of identifying the problem rather than planning interventions.

Choice D rationale:

Evaluation is the final phase of the nursing process where the nurse assesses the client’s response to the nursing actions and plan’s effectiveness towards achieving the health care goals. Since the nurse is determining the issue, not evaluating the client’s response to interventions, this phase is not the correct answer.

Choice A rationale: A Venturi mask is designed for nasal and oral use, providing specific oxygen concentrations. It cannot be properly secured or deliver effective oxygenation directly to a tracheostomy site.

Choice B rationale: A tracheostomy collar fits over the tracheostomy tube to deliver humidified oxygen. It is a primary device used during weaning to provide supplemental oxygen while allowing spontaneous breathing.

Choice C rationale: A T-piece or T-bar connects directly to the tracheostomy tube. It allows for high-flow humidified oxygen delivery and is frequently used to assess a client's readiness to breathe independently.

Choice D rationale: An aerosol mask is shaped to fit over the nose and mouth for large-volume nebulization. It is not designed to fit the neck or provide a seal for tracheostomy-specific weaning.

Choice E rationale: A mechanical ventilator is used during the weaning process through specific modes like CPAP or Pressure Support. These modes allow the client to take spontaneous breaths while providing assistance.