A client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes.
Which behaviors should the nurse prioritize for monitoring?

Clinical Rationale

Choice B (Correct): To ensure a proper seal and maintain the prescribed $FiO_2$, the mask must be secured over the bridge of the nose first, then pulled down to cover the mouth and chin. A snug fit prevents oxygen from leaking toward the eyes, which can cause irritation, and ensures the client receives the full benefit of the oxygen therapy.

Choice A (Incorrect): Simple face masks used in acute care are generally disposable, single-patient-use items. Cleaning them with soap and water is not standard practice and could introduce contaminants or moisture that compromises the equipment.

Choice C (Incorrect): A client with an oxygen saturation of 89% is hypoxic and requires continuous supplemental oxygen. Taking frequent "breaks" would cause the saturation to drop further, potentially leading to respiratory distress or cardiac strain.

Choice D (Incorrect): For an oxygen mask to be effective, it must cover both the nose and the mouth. Leaving the nose exposed allows the client to inhale room air (21% oxygen), which dilutes the supplemental oxygen and fails to reach the desired therapeutic level.

Choice E (Incorrect): Oxygen is a medication that requires a provider's order. While a nurse may titrate oxygen based on specific standing orders (e.g., "titrate to keep $SpO_2$ > 92%"), a nurse cannot unilaterally "adjust" levels without a protocol or direct order in place.

Choice A rationale
For a client who has been intubated and is on a ventilator due to sepsis, the most appropriate action based on the client’s status would be to continue weaning the ventilator as ordered.
Weaning is the process of gradually reducing ventilator support, and it is typically initiated once the underlying cause of respiratory failure has been addressed. In this case, if the client’s condition has stabilized and there are no contraindications, continuing the weaning process as ordered would be the most appropriate action.
Choice B rationale
Decreasing the tidal volume is not necessarily the most appropriate action based on the client’s status. Tidal volume is the amount of air that is inhaled or exhaled during normal breathing.
While adjustments to tidal volume may be necessary in some cases, such as if the client is experiencing discomfort or if there are concerns about lung injury, there is no information in the scenario to suggest that a decrease in tidal volume is required at this time.
Choice C rationale
Switching the ventilator to pressure control is not necessarily the most appropriate action based on the client’s status. Pressure control ventilation is a mode of ventilation that can be used in certain situations, such as when there is a need to limit airway pressures. However, there is no information in the scenario to suggest that this change is required at this time.
Choice D rationale

Increasing the fractional concentration of inspired oxygen is not necessarily the most appropriate action based on the client’s status. The fraction of inspired oxygen (FiO2) is the concentration of oxygen in the gas mixture that the client is breathing. While adjustments to FiO2 may be necessary in some cases, such as if the client’s oxygen levels are low, there is no information in the scenario to suggest that an increase in FiO2 is required at this time.
Choice E rationale
Increasing the respiratory rate is not necessarily the most appropriate action based on the client’s status. The respiratory rate is the number of breaths that the client takes per minute, and it can be adjusted on the ventilator to meet the client’s needs. However, there is no information in the scenario to suggest that an increase in the respiratory rate is required at this time.
Choice F rationale
Changing the ventilator settings to continuous positive airway pressure (CPAP) is not necessarily the most appropriate action based on the client’s status. CPAP is a mode of ventilation that can be used in certain situations, such as during the weaning process. However, there is no information in the scenario to suggest that this change is required at this time.
Choice G rationale
Alerting the provider of the blood gas values is not necessarily the most appropriate action based on the client’s status. While it is important to communicate significant changes or concerns to the provider, there is no information in the scenario to suggest that the blood gas values are abnormal or require immediate attention.