A nurse is assessing a patient who is receiving oxygen therapy via venturi mask. The nurse hears a hissing sound from the mask and observes that the patient's skin color is pale. What should the nurse say to the patient?
"I'm going to check your oxygen level with this device on your finger.”.
"You need to breathe more deeply and slowly to get enough oxygen.”.
"There is a problem with your mask and I need to fix it right away.”.
"You are getting too much oxygen and I need to lower the flow rate.".
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is C
Explanation
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.
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