A nurse is evaluating the effectiveness of oxygen therapy for a patient who has COPD. The nurse notes that the patient's PaO2 is 65 mmHg and SaO2 is 88%. What should the nurse say to the patient?
"Your oxygen levels are within the normal range for your condition.”.
"Your oxygen levels are too low and you need more oxygen.”.
"Your oxygen levels are too high and you need less oxygen.”.
"Your oxygen levels are not affected by your oxygen therapy.".
The Correct Answer is B
Choice A rationale:
The patient's PaO2 is 65 mmHg and SaO2 is 88%. PaO2 values below 80 mmHg and SaO2 below 90% are considered below normal ranges. Therefore, the patient's oxygen levels are not within the normal range for the condition.
Choice B rationale:
This is the correct choice. The patient's PaO2 and SaO2 levels indicate that they are not receiving enough oxygen, and additional oxygen therapy is needed.
Choice C rationale:
The patient's oxygen levels are low, not high. Providing less oxygen would worsen the situation.
Choice D rationale:
The patient's oxygen levels are affected by oxygen therapy, as they indicate that the current therapy is insufficient. Additional interventions are needed to improve oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A: Nasal cannula is a low-flow oxygen delivery system. It delivers a variable oxygen concentration depending on the patient's breathing pattern.
Choice B: Simple face mask is also a low-flow oxygen delivery system. It provides a variable oxygen concentration based on the patient's respiratory rate and tidal volume.
Choice C: Venturi mask is not a low-flow system. It is a high-flow oxygen delivery device that provides a fixed oxygen concentration by mixing oxygen with room air.
Choice D: Non-rebreather mask is considered a low-flow oxygen delivery system. It provides a high concentration of oxygen but does not ensure a precise oxygen concentration due to varying patient ventilation.
Correct Answer is B
Explanation
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.
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