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 C
Explanation
Choice A reason: Modifying nursing interventions is a step that may be necessary after evaluating the effectiveness of care, but it is not the immediate next action after reviewing the expected outcomes.
Choice B reason: Determining if the expected outcomes were realistic is part of the evaluation process, but it requires current data to make an informed decision.
Choice C reason: Obtaining current client data is essential to compare with the expected outcomes and determine if the goals of care are being met.
Choice D reason: Reviewing related professional standards of care is important for ensuring quality care, but it is not the direct next step in evaluating the effectiveness of the client's nursing care.
Correct Answer is B
Explanation
Choice A reason: While medication shortages can occur, this is not the typical reason for delivering a partial supply of medication for home health care.
Choice B reason: Daptomycin is an antibiotic that has a limited shelf life after it is mixed or reconstituted. This is why pharmacies often deliver only a portion of the doses to ensure the medication remains effective.
Choice C reason: Notifying the healthcare provider is necessary if there is a discrepancy in medication delivery that cannot be explained by standard pharmacy practices.
Choice D reason: Although instructions for medication administration may change, this is not the usual reason for a pharmacy to deliver a partial supply of medication.
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