A nurse is providing education to a new graduate nurse regarding the correct application and use of a simple face mask for a client with a respiratory rate of 24/min and an oxygen saturation of 89%. Which of the following statements by the new graduate nurse indicates an understanding of the procedure?
I should clean the face mask with soap and water once per shift.
I should place the mask over the bridge of the nose first and then cover the mouth.
The mask should be positioned to cover only the mouth to allow for nasal expiration.
I can adjust the oxygen flow rate independently if the client's saturation does not improve.
I can adjust the oxygen level
Correct Answer : B,C,E
Clinical Rationale
Choice B (Correct): To ensure a proper seal and maintain the prescribed $FiO_2$, the mask must be secured over the bridge of the nose first, then pulled down to cover the mouth and chin. A snug fit prevents oxygen from leaking toward the eyes, which can cause irritation, and ensures the client receives the full benefit of the oxygen therapy.
Choice A (Incorrect): Simple face masks used in acute care are generally disposable, single-patient-use items. Cleaning them with soap and water is not standard practice and could introduce contaminants or moisture that compromises the equipment.
Choice C (Incorrect): A client with an oxygen saturation of 89% is hypoxic and requires continuous supplemental oxygen. Taking frequent "breaks" would cause the saturation to drop further, potentially leading to respiratory distress or cardiac strain.
Choice D (Incorrect): For an oxygen mask to be effective, it must cover both the nose and the mouth. Leaving the nose exposed allows the client to inhale room air (21% oxygen), which dilutes the supplemental oxygen and fails to reach the desired therapeutic level.
Choice E (Incorrect): Oxygen is a medication that requires a provider's order. While a nurse may titrate oxygen based on specific standing orders (e.g., "titrate to keep $SpO_2$ > 92%"), a nurse cannot unilaterally "adjust" levels without a protocol or direct order in place.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Inquiring about the frequency of falls in recent months is an important part of a functional assessment for an older adult patient reporting decreased strength in knees and handgrips. Falls can be a sign of decreased muscle strength and balance, which can be associated with aging and certain medical conditions.
Choice B rationale
Sundowning, or increased confusion and agitation in the late afternoon and evening, is a symptom often associated with dementia, not necessarily with decreased strength in knees and handgrips.
Choice C rationale
While discussing end-of-life care options is an important aspect of comprehensive patient care, it is not directly related to the patient’s reported symptoms of decreased strength.
Choice D rationale
Requesting the patient to lie as still as possible for the assessment may not provide comprehensive information about the patient’s functional mobility and strength.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Periodic sighing and shaking of the head can be signs of agitation and distress. These behaviors may indicate that the client is struggling to manage their emotions and may need additional support or intervention.
Choice B rationale
A decreased activity level and change in affect can be signs of many different mental health conditions, but they are not typically associated with agitation. Therefore, while these behaviors should be monitored, they are not the priority in this situation.
Choice C rationale
Repeated requests for attention from the nurse can be a sign of agitation. This behavior may indicate that the client is feeling distressed and is seeking help in managing their emotions.
Choice D rationale
Argumentativeness and use of profanity are clear signs of agitation. These behaviors can escalate quickly and may pose a risk to the safety of the client and others on the unit.
Therefore, these behaviors should be prioritized for monitoring.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.