The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the client’s needs?
Partial non-rebreathing mask
Simple (Oxy Plus) mask
Nasal cannula
Non-rebreathing mask
The Correct Answer is C
A. Partial non-rebreathing mask:
This mask delivers higher concentrations of oxygen than a nasal cannula. It has a reservoir bag that allows the client to rebreathe some exhaled air, increasing the oxygen concentration delivered. However, it may not be necessary for a client with mild shortness of breath and slightly reduced oxygen saturation.
B. Simple (Oxy Plus) mask:
The simple mask provides a higher concentration of oxygen than a nasal cannula but lacks the reservoir bag found in the non-rebreathing mask. It is generally used for moderate oxygen needs. However, it might be more than what is required for a client with mild shortness of breath and slightly reduced oxygen saturation.
C. Nasal cannula:
Nasal cannulas are commonly used for clients with mild respiratory distress. They deliver a lower to moderate concentration of oxygen and are well-tolerated by most clients. They are suitable for individuals with mild shortness of breath and can be adjusted based on the required flow rate.
D. Non-rebreathing mask:
The non-rebreathing mask provides the highest concentration of oxygen among the options listed. It includes a reservoir bag to deliver a higher oxygen concentration. It is typically reserved for clients with higher oxygen requirements. For a client with mild shortness of breath and slightly reduced oxygen saturation, this may be more than necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Monitor daily weights and urine output.
Monitoring daily weights and urine output is an important aspect of managing heart failure or other cardiac conditions. However, in the context of a client with chest pain, ST elevation, and elevated cardiac enzymes (indicating a myocardial infarction), the immediate focus is on addressing the acute event and reducing myocardial oxygen demand.
B. Administer TPA to prevent further damage as a result of a clot.
Tissue plasminogen activator (TPA) is a thrombolytic medication that can be administered to dissolve blood clots in the coronary arteries during a myocardial infarction. However, the administration of TPA has a specific timeframe within which it is most effective. It is crucial to know the elapsed time since the onset of symptoms, and there are specific criteria and contraindications for its use.
C. Provide client education on medications and diet to prevent recurrence.
Client education on medications, lifestyle modifications, and dietary changes is an essential component of long-term management for preventing recurrence of cardiovascular events. However, during the acute phase of a myocardial infarction, the immediate priority is to stabilize the client and address the acute event, with education being a secondary consideration.
D. Reduce pain and myocardial oxygen demand.
During the acute phase of a myocardial infarction, reducing pain and myocardial oxygen demand is the highest priority. This is typically achieved through the administration of medications such as nitroglycerin for vasodilation and opioids for pain relief. Other interventions to optimize oxygen supply and demand, such as supplemental oxygen and reperfusion strategies, may also be considered.
Correct Answer is D
Explanation
A. The client now has developed a myocardial infarction:
A myocardial infarction (heart attack) is characterized by prolonged ischemia leading to damage or death of heart muscle cells. While the symptoms described could be concerning for a heart attack, the term "myocardial infarction" would typically imply a more sustained and severe ischemic event.
B. The client has developed Prinzmetal's angina:
Prinzmetal's angina, also known as variant angina, is characterized by chest pain that usually occurs at rest and is caused by vasospasm of the coronary arteries. The given scenario does not specifically describe the typical characteristics of Prinzmetal's angina.
C. The client now has stable angina:
Stable angina typically follows a predictable pattern and is relieved with rest and/or nitroglycerin. However, the scenario describes a change in the usual pattern of chest pain.
D. The client now has unstable angina:
Unstable angina is characterized by a change in the usual pattern of stable angina, often occurring at rest or with minimal exertion and not relieved by usual measures. This option seems to align with the information provided.
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