The nurse is caring for a client receiving oxygen therapy via a Venturi mask. Which assessment finding indicates the need for adjustment of the oxygen flow rate?

Answer: c. Applying a sterile dressing over the tracheostomy site.

Explanation: Applying a sterile dressing over the tracheostomy site helps prevent infection by providing a barrier against microorganisms. It also ensures a clean environment for optimal oxygen delivery and promotes wound healing.

Incorrect choices: a. Regularly suctioning the tracheostomy tube is important for maintaining airway patency but may not directly address infection prevention or oxygen delivery.

b. Assessing the client's respiratory rate every hour is important for monitoring respiratory status but does not specifically address infection prevention or oxygen delivery.

d. Administering humidified oxygen through the tracheostomy tube may be necessary to provide moistened air to the client's lungs but does not directly address infection prevention.

Answer: a. Removing the nasal cannula during oral care.

Explanation: To ensure effective oral care, the nurse should temporarily remove the nasal cannula while performing oral care procedures. This allows better access to the client's mouth and prevents interference with oral hygiene.

Incorrect choices: b. Increasing the oxygen flow rate during oral care is not necessary and may lead to unnecessary oxygen supplementation.

c. Applying petroleum jelly to the client's lips before oral care may be helpful for preventing dryness and chapping but is not directly related to the administration of oral care.

d. Instructing the client to breathe through the mouth during oral care is not necessary if the nasal cannula is temporarily removed to facilitate oral hygiene.