A nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen concentration?

36%

70%

50%

28%

Answer and Explanation

The Correct Answer is D

D. 28%:

When a client receives oxygen via a nasal cannula at a flow rate of 2 L/min, the approximate inspired oxygen concentration is around 24-28%. This is because each liter of oxygen delivered through a nasal cannula adds approximately 4% to the baseline room air concentration of 21%. Therefore, at 2 L/min, the client would be receiving approximately 24-28% inspired oxygen concentration.

A. 36%, B. 70%, C. 50%:

These percentages are not consistent with the oxygen concentration delivered via a nasal cannula at 2 L/min. Higher flow rates or alternative oxygen delivery systems, such as masks or high-flow nasal cannula, would be needed to achieve these concentrations.

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Correct Answer is A

Explanation

A) Headache:
Clients with obstructive sleep apnea often experience morning headaches due to the intermittent hypoxia and hypercapnia that occur during episodes of apnea. These headaches are typically described as dull and diffuse and may improve throughout the day.

B) Nausea:
While gastrointestinal symptoms such as nausea can occur in some individuals with sleep apnea, it is not a typical or specific finding associated with this condition. Nausea may result from other causes, such as medication side effects or underlying gastrointestinal issues, rather than directly from obstructive sleep apnea.

C) Hypotension:
Obstructive sleep apnea is more commonly associated with hypertension rather than hypotension. The recurrent episodes of hypoxemia and sympathetic nervous system activation during apneic episodes can lead to systemic hypertension over time.

D) Constipation:
Constipation is not a typical finding associated with obstructive sleep apnea. While sleep apnea may contribute to fatigue and alterations in gastrointestinal motility in some individuals, constipation is not a direct consequence of this sleep disorder.

A. Check residual volume every 4 to 6 hr. B. Observe client's respiratory status. C. Elevate the head of the client's bed 30" to 45". D. Monitor intake and output every 8 hr.

Correct Answer is C

Explanation

A. Check residual volume every 4 to 6 hr: While checking residual volume is an essential component of enteral feeding management, it is not the priority action in this scenario. The client's positioning to prevent aspiration takes precedence over checking residual volume.

B. Observe client's respiratory status: Monitoring respiratory status is crucial for any client with a decreased level of consciousness. However, in this case, the priority is to prevent aspiration, and positioning takes precedence over respiratory assessment.

C. Elevate the head of the client's bed 30° to 45°: The priority action for a client receiving continuous enteral feedings via a gastrostomy tube and experiencing a decreased level of consciousness is to maintain proper positioning to prevent aspiration. Elevating the head of the bed 30° to 45° helps reduce the risk of aspiration by promoting drainage of stomach contents away from the airway. This position also helps prevent reflux of gastric contents into the esophagus, which can lead to aspiration pneumonia.

D. Monitor intake and output every 8 hr: Monitoring intake and output is essential for assessing fluid balance and the effectiveness of enteral feedings. However, it is not the priority action in this situation compared to maintaining proper positioning to prevent aspiration.

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A nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen concentration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has obstructive sleep apnea. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is C

Explanation

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