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?
Increase the flow rate of oxygen to improve oxygenation.
Assess the mask bag to ensure it remains inflated during inspiration and expiration.
Switch the patient to a non-rebreather mask for higher oxygen delivery.
Reassure the patient that shortness of breath is common with this type of mask.
The Correct Answer is B
Choice A rationale:
Increasing the flow rate of oxygen may not be the priority action because the patient's shortness of breath could be due to a problem with the mask itself, rather than the amount of oxygen being delivered. Before making any adjustments to the oxygen flow rate, it is essential to assess the equipment's integrity.
Choice B rationale:
This is the priority action because a partial rebreather mask relies on the patient's exhaled breath to partially fill the reservoir bag. If the mask bag does not remain inflated during both inspiration and expiration, the patient may not be receiving the appropriate oxygen concentration, leading to increased shortness of breath. Checking the mask bag ensures that the mask is functioning correctly and delivering the intended oxygen concentration.
Choice C rationale:
Switching the patient to a non-rebreather mask for higher oxygen delivery is not the priority action in this scenario. The non-rebreather mask is used when high oxygen concentrations are required, such as in emergencies or when a patient's condition requires immediate intervention. However, the priority at this moment is to assess the current equipment's effectiveness before considering a change in oxygen delivery method.
Choice D rationale:
Reassuring the patient that shortness of breath is common with this type of mask is not appropriate without first addressing the issue at hand. The nurse should first assess the mask's functionality to ensure it is working correctly and providing the appropriate oxygen concentration before addressing the patient's concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
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.
Correct Answer is C
Explanation
Choice A rationale:
Nasal cannula delivers oxygen through two small prongs placed in the patient's nostrils. While it is a commonly used and well-tolerated device, the FiO2 delivered can vary significantly depending on the patient's breathing pattern and respiratory rate. Thus, it does not provide the most precise and consistent FiO2.
Choice B rationale:
Simple face masks cover the nose and mouth and can provide higher FiO2 levels compared to nasal cannulas. However, the FiO2 delivered still depends on the patient's breathing pattern and the mask's fit, making it less precise and consistent than other options.
Choice C rationale:
Venturi masks are designed to deliver a specific and accurate FiO2, regardless of the patient's breathing pattern. These masks have adjustable ports to control the mix of air and oxygen, providing precise oxygen concentrations.
Choice D rationale:
Non-rebreather masks have one-way valves and a reservoir bag to deliver higher concentrations of oxygen. Although they can provide high FiO2 levels, the delivered concentration can vary based on the patient's breathing pattern and the mask's fit.
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