A nurse is caring for a patient who is using a partial rebreather mask for oxygen therapy. The patient reports feeling short of breath. What is the nurse's priority action?

The correct answers are choices A, C, and E.

Choice A rationale:

A Venturi mask is designed to deliver a precise concentration of oxygen and is often used in COPD, where it is important not to over-oxygenate the patient. It allows for the adjustment of oxygen concentration by changing the color-coded entrainment adapters.

Choice B rationale:

A non-rebreather mask is not typically used for clients who require a precise concentration of oxygen because it is designed to deliver high concentrations of oxygen, but without a way to precisely control the amount.

Choice C rationale:

An aerosol mask can be used with a nebulizer system to deliver specific concentrations of oxygen along with medication, which is beneficial for COPD patients who may need bronchodilators or steroids in addition to oxygen therapy.

Choice D rationale:

A simple face mask is not suitable for delivering a precise concentration of oxygen as it does not allow for the fine control needed for COPD patients. It is generally used for short-term oxygen therapy and for patients who require a moderate amount of oxygen.

Choice E rationale:

A tracheostomy collar can provide a specific concentration of oxygen when used with a tracheostomized patient and is suitable for long-term use in COPD patients who have a tracheostomy.

In summary, for a client with COPD who requires a precise concentration of oxygen, the Venturi mask, aerosol mask, and tracheostomy collar are appropriate choices as they allow for the delivery of a specific and controlled amount of oxygen.

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.