A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best?
Assess the client’s oxygen saturation and, if normal, turn off the oxygen.
Have the client lift the mask off the face when taking bites of food.
Turn the oxygen off while the client eats the meal and then restart it.
Determine if the client can switch to a nasal cannula during the meal
The Correct Answer is D
Choice A Reason:
Assess the client’s oxygen saturation and, if normal, turn off the oxygen. This option is not ideal because turning off the oxygen completely can lead to a rapid drop in oxygen saturation levels, especially in patients who require continuous oxygen therapy. Monitoring oxygen saturation is crucial, but turning off the oxygen is not recommended unless specifically advised by a healthcare provider. Normal oxygen saturation levels typically range from 95% to 100%1. If the levels drop below 90%, it can lead to hypoxemia, which can cause serious complications.
Choice B Reason:
Have the client lift the mask off the face when taking bites of food. This option is also not ideal because it can be cumbersome for the client and may lead to inconsistent oxygen delivery. The Venturi mask is designed to provide a precise concentration of oxygen, and lifting it off repeatedly can disrupt this consistency. Additionally, it can be uncomfortable and impractical for the client to manage the mask while eating.
Choice C Reason:
Turn the oxygen off while the client eats the meal and then restart it. This option is not recommended for similar reasons as Choice A. Turning off the oxygen can lead to a significant drop in oxygen saturation levels, which can be dangerous for the client. Continuous oxygen therapy is essential for maintaining adequate oxygen levels in patients who require it. Interrupting this therapy, even temporarily, can have adverse effects on the client’s health.
Choice D Reason:
Determine if the client can switch to a nasal cannula during the meal. This is the best option because a nasal cannula allows the client to receive continuous oxygen while eating. The nasal cannula is less obtrusive and more comfortable for the client, enabling them to eat without significant interruption to their oxygen therapy. Nasal cannulas are commonly used for patients who need supplemental oxygen but also need to perform activities such as eating and talking. This approach ensures that the client maintains adequate oxygen levels while having their meal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is a) 1 cup of milk.
Choice A reason: One cup of milk contains approximately 15 grams of carbohydrates. Milk is a good source of carbohydrates, protein, and calcium, making it a suitable option for maintaining blood glucose levels during exercise. It is important for individuals with diabetes to monitor their carbohydrate intake to manage their blood sugar levels effectively.
Choice B reason: Half a cup of regular ice cream contains around 15 grams of carbohydrates. However, ice cream also contains high levels of sugar and fat, which may not be the healthiest option for regular consumption, especially for individuals with diabetes. While it can be included occasionally, it is better to choose healthier carbohydrate sources.
Choice C reason: One slice of bread typically contains about 15 grams of carbohydrates. Bread, especially whole grain or whole wheat varieties, can be a good source of carbohydrates for individuals with diabetes. It provides fiber, which helps in maintaining stable blood sugar levels.
Choice D reason: One cup of sugar-free yogurt does not contain 15 grams of carbohydrates. Sugar-free yogurt usually has fewer carbohydrates compared to regular yogurt. It is important to read the nutritional labels to determine the exact carbohydrate content. Regular yogurt, on the other hand, can be a good source of carbohydrates.
Correct Answer is D
Explanation
Choice A Reason:
Pronation of the hands.
Pronation of the hands is not typically associated with decorticate posturing. Decorticate posturing is characterized by the flexion of the arms and wrists, with the hands often clenched into fists. Pronation refers to the rotation of the hands so that the palms face downward, which is not a feature of decorticate posturing.
Choice B Reason:
Extension of the arms.
Extension of the arms is more characteristic of decerebrate posturing, not decorticate posturing. In decorticate posturing, the arms are flexed and held tightly to the chest, not extended. This flexion is due to damage to the cerebral hemispheres, which affects the corticospinal tract.
Choice C Reason:
External rotation of the lower extremities.
External rotation of the lower extremities is not a typical finding in decorticate posturing. In decorticate posturing, the legs are usually extended and rigid, with the toes pointed. External rotation would indicate a different type of posturing or neurological condition.
Choice D Reason:
Plantar flexion of the legs.
Plantar flexion of the legs is a characteristic finding in decorticate posturing. This involves the toes pointing downward, which is a result of the increased muscle tone and reflexes due to the brain injury. This posture indicates severe damage to the brain, specifically the corticospinal tract.
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