The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?
Increase the liter flow of oxygen.
Encourage the client to take deep breaths.
Remove the mask to deflate the bag.
Document the assessment data.
The Correct Answer is D
This respiratory care scenario requires applying knowledge of oxygen delivery systems and normal physiological responses. To answer correctly, the nurse must understand the mechanical function of a partial rebreather mask and recognize the significance of a normal adult respiratory rate during therapy.
Choice A rationale: Increasing the oxygen liter flow is unnecessary because the reservoir bag is already functioning correctly by not deflating completely. Liter flow for this mask must be high enough (typically 6 to 11 L/min) to keep the bag two-thirds full.
Choice B rationale: Encouraging deep breaths is not indicated as the client's respiratory rate of 14 breaths/minute is within the normal adult range of 12 to 20 breaths/minute. The current breathing pattern is effectively facilitating oxygenation without the need for coaching.
Choice C rationale: Removing the mask would interrupt oxygen therapy and is contraindicated. The reservoir bag is supposed to remain partially inflated during inhalation to ensure the client receives the prescribed oxygen concentration rather than room air or exhaled carbon dioxide.
Choice D rationale: The reservoir bag of a partial rebreather mask should not deflate completely during inspiration to prevent carbon dioxide buildup. Since the bag is functioning normally and the respiratory rate is stable, the nurse should simply document these findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Before initiating tube feeding, it is crucial to ensure that the gastrointestinal system is functioning. The presence of bowel sounds indicates peristalsis, which is necessary for the digestion and absorption of the feeding.
Choice B reason: While measuring the client's total body weight is important for overall assessment and monitoring of nutritional status, it is not the most critical assessment before starting tube feeding.
Choice C reason: Evaluating the client's ability to swallow is not relevant in this scenario since the client will be receiving nutrition through a feeding tube due to malnutrition and dehydration.
Choice D reason: Observing for signs of fluid volume deficit is important, but the immediate concern before starting tube feeding is to confirm gastrointestinal activity through the presence of bowel sounds.
Correct Answer is B
Explanation
Choice A reason: While unpleasant odor can indicate poor oral hygiene or other health issues, it is not as urgent as some other findings.
Choice B reason: White patches on the mucosa can indicate an infection such as oral thrush, which requires medical treatment, making it the most important finding to act upon.
Choice C reason: A receding gumline is a concern for dental health but does not typically require immediate action.
Choice D reason: Discoloration of teeth can indicate various issues, including dietary habits or decay, but is not as immediately concerning as white patches on the mucosa. Bolded text indicates the correct answers and important information.
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