Choice A rationale:

The goal of oxygen therapy is not to provide the highest fraction of inspired oxygen (FiO2) possible. This approach can be harmful because excessively high FiO2 levels can lead to oxygen toxicity and other side effects, especially in patients with certain conditions like chronic obstructive pulmonary disease (COPD).

Choice B rationale:

The goal of oxygen therapy is to use the lowest FiO2 that achieves an acceptable blood oxygen level without harmful side effects. This approach is known as titrating the oxygen therapy to the patient's needs and helps prevent potential complications associated with excessive oxygen administration.

Choice C rationale:

Maintaining a constant FiO2 regardless of the patient's breathing pattern is not the goal of oxygen therapy. In some cases, patients may require varying FiO2 levels based on their respiratory status, so it is essential to adjust the oxygen delivery accordingly.

Choice D rationale:

Delivering a fixed amount of oxygen that is independent of the patient's condition is not the goal of oxygen therapy. Oxygen therapy should be individualized and tailored to the patient's specific needs to optimize its effectiveness and safety.

Choice A rationale:

Nasal cannula is a low-flow oxygen delivery system because the oxygen flow rate is relatively low and the delivered oxygen is mixed with room air before reaching the patient's lungs.

Choice B rationale:

The simple face mask is a low-flow oxygen delivery system. It delivers oxygen at a fixed flow rate and allows room air to mix with the delivered oxygen.

Choice C rationale:

Venturi mask is not a low-flow oxygen delivery system. It is a high-flow system that provides a specific and precise FiO2, making it suitable for patients with chronic respiratory conditions.

Choice D rationale:

The non-rebreather mask is not a low-flow oxygen delivery system. It is a high-flow system that is used when the patient requires a high FiO2, close to 100%, to ensure adequate oxygenation.

Choice E rationale:

Aerosol mask is a low-flow oxygen delivery system that delivers oxygen mixed with aerosolized medication. The flow rate is relatively low compared to high-flow systems.

Choice A rationale:

Switching to a simple face mask is not the appropriate intervention for nasal dryness and irritation. A simple face mask covers the nose and mouth, and it may not provide enough relief for nasal dryness as the oxygen flow is still directed towards the nose.

Choice B rationale:

Increasing the flow rate of oxygen will not directly improve humidity. Nasal dryness and irritation are often caused by the lack of moisture in the delivered oxygen. Increasing the flow rate may worsen the issue.

Choice C rationale:

Assessing the patient's nares for patency and skin integrity is the appropriate intervention. Nasal dryness and irritation can be caused by inadequate humidification of the oxygen. Checking the patency of the nares and the condition of the skin can help identify any issues that may be contributing to the discomfort.

Choice D rationale:

Reassuring the patient that nasal dryness is a normal side effect is not sufficient. While nasal dryness can be a common side effect of using a nasal cannula, it is essential to address the issue and provide appropriate interventions to alleviate the discomfort and prevent complications.

Choice A rationale:

Increasing the flow rate of oxygen may not be the priority action because the patient's shortness of breath could be due to a problem with the mask itself, rather than the amount of oxygen being delivered. Before making any adjustments to the oxygen flow rate, it is essential to assess the equipment's integrity.

Choice B rationale:

This is the priority action because a partial rebreather mask relies on the patient's exhaled breath to partially fill the reservoir bag. If the mask bag does not remain inflated during both inspiration and expiration, the patient may not be receiving the appropriate oxygen concentration, leading to increased shortness of breath. Checking the mask bag ensures that the mask is functioning correctly and delivering the intended oxygen concentration.

Choice C rationale:

Switching the patient to a non-rebreather mask for higher oxygen delivery is not the priority action in this scenario. The non-rebreather mask is used when high oxygen concentrations are required, such as in emergencies or when a patient's condition requires immediate intervention. However, the priority at this moment is to assess the current equipment's effectiveness before considering a change in oxygen delivery method.

Choice D rationale:

Reassuring the patient that shortness of breath is common with this type of mask is not appropriate without first addressing the issue at hand. The nurse should first assess the mask's functionality to ensure it is working correctly and providing the appropriate oxygen concentration before addressing the patient's concerns.

Choice A rationale:

Although a tracheostomy collar provides oxygen directly to the trachea, the advantage specified in the question is related to the ability to breathe room air when disconnected from the oxygen source.

Choice B rationale:

This is the correct answer because a tracheostomy collar has an opening that allows the patient to breathe room air when the oxygen source is disconnected. This feature enables the patient to participate in activities without continuous oxygen delivery, promoting mobility and reducing the feeling of being tethered to an oxygen supply.

Choice C rationale:

A tracheostomy collar does not provide the highest fraction of inspired oxygen (FiO2) among low-flow systems. High-flow systems, such as non-rebreather masks or venturi masks, typically provide the highest FiO2.

Choice D rationale:

A tracheostomy collar does not deliver a fixed amount of oxygen independent of the patient's breathing pattern. Instead, it provides supplemental oxygen in response to the patient's inspiratory effort, which is a characteristic of low-flow oxygen delivery systems.

Choice A rationale:

Nasal cannula delivers low to moderate concentrations of oxygen and may not be effective for a client with thick secretions, dry mucous membranes, or upper airway edema. Additionally, the nasal cannula may not provide sufficient humidification to alleviate these conditions.

Choice B rationale:

The simple face mask is not ideal for a client with thick secretions, dry mucous membranes, or upper airway edema as it may not provide enough humidification and could be uncomfortable for the patient.

Choice C rationale:

A partial rebreather mask also may not be the most appropriate choice for this client as it has a reservoir bag that may not adequately humidify the oxygen, leading to discomfort and potential worsening of dry mucous membranes.

Choice D rationale:

The aerosol mask is the most appropriate choice because it delivers humidified oxygen in the form of small aerosol particles, which can help alleviate thick secretions, moisturize dry mucous membranes, and reduce upper airway edema. This mask is beneficial for patients who require higher humidity levels to maintain airway patency and comfort.

Choice A rationale:

Nasal cannula delivers oxygen through two small prongs placed in the patient's nostrils. While it is a commonly used and well-tolerated device, the FiO2 delivered can vary significantly depending on the patient's breathing pattern and respiratory rate. Thus, it does not provide the most precise and consistent FiO2.

Choice B rationale:

Simple face masks cover the nose and mouth and can provide higher FiO2 levels compared to nasal cannulas. However, the FiO2 delivered still depends on the patient's breathing pattern and the mask's fit, making it less precise and consistent than other options.

Choice C rationale:

Venturi masks are designed to deliver a specific and accurate FiO2, regardless of the patient's breathing pattern. These masks have adjustable ports to control the mix of air and oxygen, providing precise oxygen concentrations.

Choice D rationale:

Non-rebreather masks have one-way valves and a reservoir bag to deliver higher concentrations of oxygen. Although they can provide high FiO2 levels, the delivered concentration can vary based on the patient's breathing pattern and the mask's fit.

Choice A rationale:

Venturi masks are not typically used with tracheostomy patients, as they are more suitable for patients with intact upper airways.

Choice B rationale:

Tracheostomy collars are specifically designed for patients with tracheostomies. They provide oxygen directly to the tracheostomy tube, making them appropriate for weaning tracheostomized patients from mechanical ventilation.

Choice C rationale:

T-piece adapters are commonly used for patients with tracheostomies to deliver oxygen. They are simple devices that deliver oxygen directly to the tracheostomy tube.

Choice D rationale:

Aerosol masks are not specifically designed for tracheostomy patients and may not provide adequate oxygen delivery for them.

Choice E rationale:

Mechanical ventilators are not an oxygen delivery device; instead, they are used to provide mechanical ventilation support to the patient and can incorporate various oxygen delivery systems.

Choice A rationale:

At a flow rate of 4 L/min, oxygen therapy through a nasal cannula can increase the risk of oxygen toxicity, especially if used for prolonged periods. Oxygen toxicity can cause damage to the lungs and other organs.

Choice B rationale:

Carbon dioxide retention is not a common complication at this flow rate. It may occur in patients with severe chronic obstructive pulmonary disease (COPD) at higher oxygen flow rates.

Choice C rationale:

Nasal dryness is a common but relatively minor complication of oxygen therapy via nasal cannula. It can cause discomfort but is not a severe concern.

Choice D rationale:

Fire hazard is not directly related to the use of a nasal cannula but rather to the use of oxygen in the presence of flammable materials or near open flames. It is a concern for all oxygen delivery devices, not specific to nasal cannulas.

Choice A rationale:

The nurse should use a Venturi mask for a client with COPD requiring a precise concentration of oxygen. The Venturi mask delivers a specific oxygen concentration by mixing oxygen with room air through a venturi effect, ensuring accurate and consistent oxygen delivery.

Choice B rationale:

The non-rebreather mask is not the best choice for a client requiring a precise oxygen concentration. It is used for short-term, high-flow oxygen therapy and is not adjustable, making it unsuitable for precise oxygen delivery.

Choice C rationale:

The aerosol mask is used for delivering humidified oxygen and is not designed to deliver precise oxygen concentrations like the Venturi mask.

Choice D rationale:

The simple face mask is also not the best choice for a precise oxygen concentration. It delivers higher concentrations of oxygen but lacks the ability to fine-tune the delivered oxygen percentage like the Venturi mask.

Choice E rationale:

The tracheostomy collar is used for clients with a tracheostomy and does not provide precise oxygen concentrations like the Venturi mask.

Choice A rationale:

Refilling the oxygen tank based on the client's perception of it feeling light and empty is not a reliable method, as it may lead to running out of oxygen unexpectedly.

Choice B rationale:

The nurse should instruct the client to refill the oxygen tank when the pressure gauge reads below 500 psi. This is a standardized method to ensure the client does not run out of oxygen, as the pressure gauge provides an accurate measure of the remaining oxygen in the tank.

Choice C rationale:

Refilling the tank when a hissing sound is heard from the valve is not a valid method for determining the need for a refill and may result in running out of oxygen.

Choice D rationale:

Waiting for an alarm sound from the regulator to refill the tank is not recommended, as the tank could run out of oxygen before the alarm activates.

Choice A rationale:

Impaired gas exchange is assessed during the "Assessment”. phase of the nursing process. The nurse gathers data on the client's respiratory rate, cyanosis, and dyspnea to determine the presence of impaired gas exchange.

Choice B rationale:

Diagnosis in the nursing process involves identifying the client's health problems based on the assessment data. It does not specifically address impaired gas exchange during this phase.

Choice C rationale:

Planning involves setting goals and outcomes for the client's care. While addressing impaired gas exchange may be part of the plan, it is not the phase in which the nurse determines the client's gas exchange status.

Choice D rationale:

Evaluation is the phase of the nursing process where the nurse assesses the client's response to interventions and determines the effectiveness of the care provided. It does not directly relate to identifying impaired gas exchange.

SaO2 88%.

Choice A rationale:

A PaO2 of 80 mmHg is not an appropriate indicator of oxygen therapy effectiveness. While it's within the normal range (80-100 mmHg), it doesn't specifically reflect the effectiveness of oxygen therapy in this scenario.

Choice B rationale:

A SaO2 of 88% is an appropriate indicator of oxygen therapy effectiveness. Oxygen saturation (SaO2) measures the percentage of hemoglobin that is bound with oxygen. An SaO2 of 88% is considered an acceptable level, indicating that the oxygen therapy is effectively improving the oxygenation of the patient's blood.

Choice C rationale:

A respiratory rate (RR) of 32/min is not a specific indicator of oxygen therapy effectiveness. It may be within the normal range (12-20 breaths/min for adults), but it can be affected by various factors, not just oxygen therapy.

Choice D rationale:

A blood pressure (BP) of 160/90 mmHg is not a direct indicator of oxygen therapy effectiveness. While high blood pressure can be associated with hypoxia, it is not specific enough to determine the effectiveness of oxygen therapy in this case.

A humidifier.

Choice A rationale:

A humidifier is necessary to prevent complications in a patient receiving oxygen therapy via a tracheostomy collar. Oxygen delivered through a tracheostomy can dry out the airways and cause discomfort and potential complications. Adding humidity helps maintain airway moisture and prevents drying of the mucous membranes, reducing the risk of mucus plugs and irritation.

Choice B rationale:

A water seal is not necessary for a patient receiving oxygen therapy via a tracheostomy collar. Water seals are used in chest drainage systems to prevent air from entering the pleural space, but they are not relevant in this scenario.

Choice C rationale:

A suction catheter is used to clear secretions from the airway but is not directly related to preventing complications with oxygen therapy via a tracheostomy collar.

Choice D rationale:

A chest tube is not needed for a patient receiving oxygen therapy via a tracheostomy collar. Chest tubes are inserted to drain fluid or air from the pleural space, which is not applicable to this situation.

Keep the reservoir bag fully inflated at all times.

Choice A rationale:

In a partial rebreather mask, the reservoir bag should be kept fully inflated at all times to ensure the delivery of the highest possible oxygen concentration during inspiration. The bag collects oxygen during expiration, and the one-way valve prevents the exhaled gases from entering the bag. This way, the patient can inhale a mixture of oxygen from the reservoir and fresh oxygen flow.

Choice B rationale:

Breathing through the mouth and exhaling through the nose is not a necessary instruction for a patient using a partial rebreather mask. It doesn't directly impact the effectiveness of oxygen delivery.

Choice C rationale:

Adjusting the elastic strap to fit snugly around the face is not specific to ensuring effective oxygen delivery. It is a general guideline for mask fitting but doesn't directly affect oxygen administration.

Choice D rationale:

Removing the mask every 15 minutes to check the skin is not necessary and can disrupt the delivery of oxygen therapy. It's essential to maintain a consistent oxygen supply to the patient's lungs, and removing the mask frequently can compromise that. Checking the skin can be done periodically without removing the mask completely.

Choice A rationale:

The non-rebreather mask delivers the highest concentration of oxygen among low-flow systems. This is because the mask has a reservoir bag that fills with oxygen during inhalation, preventing the patient from breathing in room air and allowing them to receive a higher concentration of oxygen.

Choice B rationale:

The non-rebreather mask prevents the patient from rebreathing exhaled air. It has one-way valves that prevent exhaled air from being inhaled again, reducing the risk of carbon dioxide retention.

Choice E rationale:

The non-rebreather mask minimizes the risk of carbon dioxide retention. The presence of one-way valves in the mask ensures that the patient exhales carbon dioxide without rebreathing it, maintaining a proper oxygen and carbon dioxide exchange.

Choice C rationale:

The non-rebreather mask does not provide consistent and precise oxygen delivery. It is a low-flow system, and the delivered oxygen concentration may vary depending on the patient's breathing patterns and other factors.

Choice D rationale:

The non-rebreather mask does not allow room air to enter through exhalation ports. It is a closed system with one-way valves that only permit oxygen to flow into the mask during inhalation.

Questions.

Choice D rationale:

The nurse should connect the nasal cannula to a humidifier first. Dry and irritated nares are common side effects of oxygen therapy via nasal cannula, and using a humidifier adds moisture to the oxygen, reducing irritation and discomfort for the patient.

Choice A rationale:

Applying petroleum jelly to the nares is not the first action to take. It might provide temporary relief, but it is essential to address the root cause of dryness, which is the lack of moisture in the oxygen delivered.

Choice B rationale:

Increasing the flow rate of oxygen is not the first step because it may not address the dryness issue. It can lead to a higher concentration of oxygen, but it won't solve the problem of dry and irritated nares.

Choice C rationale:

Changing the nasal cannula to a face mask is not necessary to address the dryness. Face masks may not be well-tolerated by some patients, and it's better to try less invasive interventions first.

Choice A rationale:

The nurse should instruct the patient to avoid smoking or being near open flames while using oxygen. Oxygen supports combustion, and smoking or exposure to flames can lead to a fire hazard.

Choice C rationale:

Checking the position of the oxygen delivery device frequently is important to ensure proper oxygen delivery and avoid any displacement or obstruction that may compromise the therapy's effectiveness.

Choice D rationale:

Instructing the patient to report any signs of hypoxia (low oxygen levels) or hypercarbia (high carbon dioxide levels) to the provider is crucial for early detection of potential complications and appropriate management.

Choice E rationale:

Instructing the patient to adjust the flow rate of oxygen as needed allows them to respond to varying oxygen requirements, especially during activities or changes in their respiratory condition.

Choice B rationale:

Using cotton or wool clothing and bedding is not a recommended instruction for oxygen therapy. Synthetic materials are preferred as they are less likely to catch fire compared to cotton or wool.

Choice A rationale:

The nurse should not immediately check the patient's oxygen level with a finger device because the priority is to address the hissing sound from the mask and the patient's pale skin color, which could indicate inadequate oxygen delivery.

Choice B rationale:

Instructing the patient to breathe more deeply and slowly won't address the issue of the hissing sound and the possible oxygen delivery problem. The nurse should address the equipment issue first.

Choice C rationale:

This is the correct choice. The nurse should inform the patient that there is a problem with the mask, and it needs to be fixed promptly to ensure adequate oxygen therapy.

Choice D rationale:

Lowering the flow rate may not be appropriate until the nurse has assessed and resolved the problem with the mask. It's essential to troubleshoot the equipment first.

Choice A rationale:

The patient's PaO2 is 65 mmHg and SaO2 is 88%. PaO2 values below 80 mmHg and SaO2 below 90% are considered below normal ranges. Therefore, the patient's oxygen levels are not within the normal range for the condition.

Choice B rationale:

This is the correct choice. The patient's PaO2 and SaO2 levels indicate that they are not receiving enough oxygen, and additional oxygen therapy is needed.

Choice C rationale:

The patient's oxygen levels are low, not high. Providing less oxygen would worsen the situation.

Choice D rationale:

The patient's oxygen levels are affected by oxygen therapy, as they indicate that the current therapy is insufficient. Additional interventions are needed to improve oxygenation.

Choice A rationale:

Monitoring the patient's respiratory rate, depth, rhythm, and effort is crucial for assessing the effectiveness of oxygen therapy and ensuring proper oxygenation through the tracheostomy collar.

Choice B rationale:

Educating the patient on how to use and care for the tracheostomy collar is essential to ensure the patient's safety and compliance with the therapy.

Choice C rationale:

Implementing safety measures to prevent fire hazards from the oxygen source is crucial, especially when oxygen is delivered via tracheostomy collar, which may have increased oxygen flow rates.

Choice D rationale:

This is the correct choice. All the provided interventions (monitoring respiratory parameters, patient education, and safety measures) are essential components of the plan of care for a patient with a tracheostomy who requires oxygen therapy.

Choice A rationale:

Monitoring the patient's respiratory rate, depth, rhythm, and effort is crucial for assessing the effectiveness of oxygen therapy and ensuring proper oxygenation through the tracheostomy collar.

Choice B rationale:

Educating the patient on how to use and care for the tracheostomy collar is essential to ensure the patient's safety and compliance with the therapy.

Choice C rationale:

Implementing safety measures to prevent fire hazards from the oxygen source is crucial, especially when oxygen is delivered via tracheostomy collar, which may have increased oxygen flow rates.

Choice D rationale:

This is the correct choice. All the provided interventions (monitoring respiratory parameters, patient education, and safety measures) are essential components of the plan of care for a patient with a tracheostomy who requires oxygen therapy.