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?
PaO2 80 mmHg.
SaO2 88%.
RR 32/min.
BP 160/90 mmHg.
The Correct Answer is A
The correct answer is choice a. PaO2 80 mmHg.
Choice A rationale:
PaO2 (partial pressure of oxygen in arterial blood) of 80 mmHg indicates that the oxygen therapy has been effective. Normal PaO2 levels range from 75 to 100 mmHg, so a value of 80 mmHg suggests adequate oxygenation.
Choice B rationale:
SaO2 (arterial oxygen saturation) of 88% is below the normal range (typically 95-100%) and indicates hypoxemia, suggesting that the oxygen therapy has not been fully effective.
Choice C rationale:
A respiratory rate (RR) of 32 breaths per minute is significantly higher than the normal range (12-20 breaths per minute) and indicates respiratory distress, suggesting that the oxygen therapy has not been effective.
Choice D rationale:
Blood pressure (BP) of 160/90 mmHg is elevated and indicates hypertension, which is not a direct measure of the effectiveness of oxygen therapy. This finding does not provide information about the patient’s oxygenation status.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Monitoring the patient's respiratory rate, depth, rhythm, and effort is crucial for assessing the effectiveness of oxygen therapy and ensuring proper oxygenation through the tracheostomy collar.
Choice B rationale:
Educating the patient on how to use and care for the tracheostomy collar is essential to ensure the patient's safety and compliance with the therapy.
Choice C rationale:
Implementing safety measures to prevent fire hazards from the oxygen source is crucial, especially when oxygen is delivered via tracheostomy collar, which may have increased oxygen flow rates.
Choice D rationale:
This is the correct choice. All the provided interventions (monitoring respiratory parameters, patient education, and safety measures) are essential components of the plan of care for a patient with a tracheostomy who requires oxygen therapy.
Correct Answer is D
Explanation
Choice D rationale:
The nurse should connect the nasal cannula to a humidifier first. Dry and irritated nares are common side effects of oxygen therapy via nasal cannula, and using a humidifier adds moisture to the oxygen, reducing irritation and discomfort for the patient.
Choice A rationale:
Applying petroleum jelly to the nares is not the first action to take. It might provide temporary relief, but it is essential to address the root cause of dryness, which is the lack of moisture in the oxygen delivered.
Choice B rationale:
Increasing the flow rate of oxygen is not the first step because it may not address the dryness issue. It can lead to a higher concentration of oxygen, but it won't solve the problem of dry and irritated nares.
Choice C rationale:
Changing the nasal cannula to a face mask is not necessary to address the dryness. Face masks may not be well-tolerated by some patients, and it's better to try less invasive interventions first.
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