The SpO2 of a client receiving oxygen therapy by nasal cannula at 6 L/min has dropped from 94% an hour ago to 90%. Which action does the nurse perform first to improve gas exchange before reporting the change to the primary health care provider?

Tighten the straps on the nasal cannula

Increase the oxygen flow rate to 8 L/min

Check the tubing for kinks, leaks, or obstructions

Check to determine whether the oxygen delivery system is adequately humidified

Answer and Explanation

The Correct Answer is C

A. While properly securing the cannula is important for comfort and consistent oxygen delivery, it is unlikely to be the primary cause of a significant drop in SpO2 unless the cannula is completely dislodged.

B. Immediately increasing the flow rate without assessing the equipment or patient may be premature. The drop in SpO2 could be caused by mechanical issues or patient factors that need to be addressed first. Additionally, flow rates above 6 L/min are generally not recommended for standard nasal cannula because they can cause mucosal dryness and discomfort.

C. The first action is to ensure the oxygen delivery system is functioning properly, as tubing obstruction, disconnection, or leaks are common, reversible causes of hypoxemia. Correcting these issues can immediately improve oxygenation before escalating care or altering prescriptions.

D. Humidification improves comfort and prevents mucosal dryness, but it does not immediately affect oxygen saturation. Ensuring proper tubing function takes priority.

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Correct Answer is C

Explanation

A. Administering stress ulcer prophylaxis(such as a proton pump inhibitor or H2 blocker) is a component of VAP prevention bundles, as gastric acid suppression reduces the risk of aspiration-related pneumonia. This statement is correct and does not indicate misunderstanding.

B. Elevating the head of the bed 30–45°is a key VAP prevention measure, as it decreases risk of aspiration of gastric contents. This statement demonstrates proper understanding.

C. Continuous deep sedation is not recommendedfor VAP prevention. Over-sedation increases immobility, delays weaning, and increases the risk of VAP. The preferred practice is daily sedation interruption or light sedation, allowing assessment of readiness for weaning and reducing complications. This statement indicates the family needs additional teaching about sedation practices.

D. Low-dose anticoagulation (e.g., heparin) is used for venous thromboembolism (VTE) prophylaxisin mechanically ventilated patients and is part of standard critical care bundles. It does not directly prevent VAP but is appropriate care.

A. Teaching cigarette smoking cessation. B. Maintaining adequate serum potassium levels. C. Monitoring clients for signs of hypercapnia. D. Replacing fluids adequately during hypovolemic states.

Correct Answer is D

Explanation

A. Smoking cessation improves long-term respiratory healthand decreases the risk of chronic lung diseases such as COPD and lung cancer. However, ARDS is an acute inflammatory lung injury, typically triggered by severe illness, trauma, sepsis, or massive transfusions. Smoking status does not acutely prevent ARDSfrom developing in critically ill patients.

B. While maintaining electrolyte balanceis essential for cellular and cardiac function, potassium levels do not have a direct preventive effect on ARDS. Electrolyte monitoring supports general critical care but does not influence the pathophysiology of acute lung injury.

C. Monitoring for hypercapnia is a reactive measureto detect respiratory compromise, but it does not prevent ARDS. It may help in early recognition of respiratory failure once it begins, but it cannot stop the initial inflammatory cascade or alveolar injurythat causes ARDS.

D. ARDS often develops secondary to shock or hypoperfusion, where decreased circulating volume leads to systemic inflammation, increased capillary permeability, and pulmonary edema. Timely fluid resuscitation maintains adequate tissue perfusion, preserves oxygen delivery, and reduces the risk of alveolar damage and progression to ARDS. Proper fluid management also helps prevent organ hypoxia and multi-organ dysfunction, which are common contributors to ARDS development.

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The SpO2 of a client receiving oxygen therapy by nasal cannula at 6 L/min has dropped from 94% an hour ago to 90%. Which action does the nurse perform first to improve gas exchange before reporting the change to the primary health care provider?

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Naxlex Comprehensive Predictor Exams

The nurse is teaching the spouse of a client on mechanical ventilation about measures to prevent ventilator associated pneumonia. Which of the following statements by the family would indicate to the nurse that the family would indicate to the nurse that the family needs additional instruction?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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