When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?
Assess the position of the mask on the client's face.
Release and reinsert the flowmeter in the wall outlet.
Attach the flowmeter to a humidification canister.
Adjust the flow rate to the prescribed liters per minute.
The Correct Answer is B
Choice A reason: Assessing the position of the mask on the client's face is not the priority action. The mask may be well-fitted, but the oxygen delivery may be compromised by the faulty connection of the flowmeter.
Choice B reason: Releasing and reinserting the flowmeter in the wall outlet is the best action as it may correct the problem of the loose or misaligned connection. The nurse should ensure that the flowmeter is securely attached and that the oxygen is flowing properly.
Choice C reason: Attaching the flowmeter to a humidification canister is not necessary for oxygen delivery per mask. Humidification is usually added for high-flow oxygen devices such as nasal cannula or face tent.
Choice D reason: Adjusting the flow rate to the prescribed liters per minute is not the appropriate action. The flow rate may be correct, but the oxygen delivery may be impaired by the hissing sound indicating a leak or obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Applying lubricant to the cannula tubing is not the best intervention as it may cause irritation or infection of the nasal mucosa. The nurse should use water-soluble gel or saline spray to moisten the nasal passages if needed.
Choice B reason: Placing padding around the cannula tubing is the best intervention as it prevents friction and pressure on the skin. The nurse should use soft materials such as gauze or foam to cushion the tubing and check the skin integrity frequently.
Choice C reason: Decreasing the flow rate to 1 L/minute is not an appropriate intervention as it may compromise the client's oxygenation. The nurse should maintain the prescribed flow rate and monitor the client's vital signs and oxygen saturation.
Choice D reason: Discontinuing the use of the nasal cannula is not an option as it may endanger the client's life. The nurse should continue the oxygen therapy as ordered and provide comfort measures and education to the client.
Correct Answer is A
Explanation
Choice A reason: This is the most therapeutic response as it invites the client to share her feelings and thoughts about the visit. It also shows the nurse's interest and empathy for the client.
Choice B reason: This is a less therapeutic response as it is vague and non-specific. It does not address the client's behavior or mood. It also puts the burden on the client to initiate the conversation.
Choice C reason: This is a less therapeutic response as it assumes that the client enjoyed the visit. It may not reflect the client's true feelings or experiences. It also limits the client's expression to positive aspects only.
Choice D reason: This is a non-therapeutic response as it labels the client's emotion without validation. It may not accurately describe the client's feeling or situation. It also closes the communication by making a statement instead of asking a question.
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