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Showing 10 questions, Sign in for moreWhen administering oxygen therapy, which intervention should the nurse prioritize to ensure the delivery of the prescribed oxygen concentration?
Explanation
Answer: c. Monitoring the client's oxygen saturation continuously.
Explanation: Continuous monitoring of the client's oxygen saturation allows the nurse to assess the effectiveness of oxygen therapy and ensure the prescribed oxygen concentration is being delivered. It helps in making timely adjustments to the oxygen therapy to maintain adequate oxygenation.
Incorrect choices: a. Assessing the client's respiratory rate every hour is important but does not directly ensure the delivery of the prescribed oxygen concentration.
b. Checking the oxygen flow rate every 4 hours is important for monitoring equipment functionality but does not directly ensure the delivery of the prescribed oxygen concentration.
d. Adjusting the oxygen mask snugly on the client's face is important for proper fit and oxygen delivery, but it does not directly ensure the delivery of the prescribed oxygen concentration.
Which statement by a client on oxygen therapy indicates the need for further education?
Explanation
Answer: b. "I will secure the oxygen tubing under furniture legs."
Explanation: Securing the oxygen tubing under furniture legs can create a potential safety hazard by causing the tubing to become twisted or pulled, disrupting the oxygen flow. It is important to educate the client about keeping the tubing free from obstructions and ensuring it is positioned safely.
Incorrect choices: a. "I should avoid smoking while using oxygen" is a correct statement, as smoking near oxygen can be extremely dangerous and increase the risk of fire.
c. "I will keep the oxygen equipment away from open flames" is a correct statement, as oxygen supports combustion and can cause a fire if exposed to open flames.
d. "I will use a water-based moisturizer for dry nasal passages" is a correct statement, as oxygen therapy can cause dryness in the nasal passages, and using a water-based moisturizer can help alleviate discomfort.
When caring for a client receiving oxygen therapy, the nurse identifies condensation in the oxygen tubing. What action should the nurse take?
Explanation
Answer: b. Disconnect the tubing and drain the condensation.
Explanation: Condensation in the oxygen tubing can impede the flow of oxygen and reduce the effectiveness of oxygen therapy. The nurse should disconnect the tubing and drain the condensation before reconnecting and continuing oxygen therapy.
Incorrect choices: a. Increasing the oxygen flow rate does not address the issue of condensation and may lead to unnecessary oxygen supplementation.
c. Replacing the oxygen tubing with a new one immediately may not be necessary if the condensation can be resolved by draining it.
d. Placing a heat-moisture exchanger (HME) on the oxygen tubing is not necessary for managing condensation but can be used to provide humidification for clients receiving high-flow oxygen therapy.
The nurse is caring for a client receiving oxygen therapy via a simple face mask. Which nursing intervention is important to prevent skin breakdown?
Explanation
Answer: c. Padding the pressure points on the client's face with soft material.
Explanation: Oxygen masks, especially those that exert pressure on specific areas of the face, can cause skin breakdown and pressure ulcers. Padding the pressure points with soft material helps distribute the pressure more evenly and reduces the risk of skin damage.
Incorrect choices: a. Changing the position of the mask every 2 hours is important for preventing pressure ulcers related to prolonged pressure on the skin but may not directly address the pressure points created by the mask.
b. Applying a protective barrier cream to the client's face is not specifically indicated for preventing pressure ulcers caused by oxygen masks. It is more commonly used for preventing moisture-associated skin damage.
d. Encouraging the client to remove the mask intermittently for facial skin care may compromise oxygen delivery and is not recommended unless otherwise specified by the healthcare provider.
The nurse is caring for a client receiving oxygen therapy via a nasal cannula. Which action by the nurse is appropriate when providing oral care to the client?
Explanation
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.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) receiving long-term oxygen therapy at home. What should the nurse include in the client's teaching regarding oxygen safety?
Explanation
Answer: c. "Avoid using electric heating devices in your home."
Explanation: Oxygen supports combustion, and using electric heating devices in the presence of oxygen therapy can pose a significant fire hazard. It is important to educate clients with long-term oxygen therapy about the importance of avoiding open flames and electric heating devices to ensure their safety.
Incorrect choices: a. Ensuring a fire extinguisher is readily available is a good general safety practice but may not directly address the specific risk associated with oxygen therapy.
b. Keeping the oxygen tubing loose may increase the risk of tangling and accidental disconnection. The tubing should be appropriately secured and free from obstructions.
d. Using an oxygen concentrator for outdoor activities may not be necessary for all clients and should be based on individual needs and healthcare provider recommendations.
The nurse is assessing a client who is receiving high-flow oxygen therapy via a non-rebreather mask. Which finding requires immediate intervention?
Explanation
Answer: d. Loose fit of the mask on the client's face.
Explanation: A loose fit of the mask on the client's face can result in a significant reduction in the delivery of high-flow oxygen therapy. It is essential to ensure a proper seal and fit of the mask to maximize the effectiveness of oxygen therapy. Immediate intervention is needed to readjust and secure the mask properly.
Incorrect choices: a. An oxygen flow rate of 10 L/min may be appropriate for high-flow oxygen therapy, depending on the client's condition and prescribed treatment.
b. An oxygen saturation of 95% indicates adequate oxygenation and is within the target range for most clients.
c. Condensation in the mask can be managed by draining it appropriately and does not necessarily require immediate intervention unless it significantly obstructs oxygen flow.
The nurse is caring for a client with a tracheostomy receiving oxygen therapy. Which intervention should the nurse prioritize to prevent infection and ensure proper oxygen delivery?
Explanation
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.
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?
Explanation
Answer: c. Client reporting nasal dryness and discomfort.
Explanation: The client reporting nasal dryness and discomfort indicates inadequate humidification of the oxygen. The nurse should assess and adjust the oxygen flow rate or consider providing humidified oxygen to alleviate the client's discomfort.
Incorrect choices: a. An oxygen saturation of 98% indicates adequate oxygenation and does not necessitate an adjustment in the oxygen flow rate.
b. A respiratory rate of 16 breaths per minute within the normal range does not indicate a need for adjustment of the oxygen flow rate.
d. An oxygen flow rate set at 4 L/min may be appropriate for a Venturi mask, depending on the prescribed oxygen concentration and the client's needs.
The nurse is caring for a client receiving oxygen therapy via a face tent. Which action by the nurse is important to ensure proper oxygen delivery?
Explanation
Answer: c. Frequently checking for condensation inside the face tent.
Explanation: Checking for condensation inside the face tent is important to ensure that the oxygen is effectively delivered to the client. Condensation can obstruct the flow ofoxygen and reduce its effectiveness. The nurse should frequently check for condensation and take appropriate measures to maintain proper oxygen delivery.
Incorrect choices: a. Adjusting the face tent to fit snugly around the client's face may cause discomfort and impede proper oxygen delivery. The face tent should be loosely fitted to allow adequate airflow.
b. Ensuring the client breathes through the nose during oxygen therapy is not necessary with a face tent, as it covers both the nose and mouth, allowing the client to breathe through either.
d. Monitoring the client's oxygen saturation every 8 hours is not frequent enough for clients receiving oxygen therapy. Continuous or regular monitoring is typically necessary to assess the effectiveness of oxygen therapy and adjust as needed.
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