A nurse is caring for a client who has been receiving oxygen via simple face mask for 6 hours. Which of the following assessment findings indicates that oxygen therapy has been effective?
PaO2 80 mmHg.
SaO2 88%.
RR 32/min.
BP 160/90 mmHg.
The Correct Answer is A
The correct answer is choice a. PaO2 80 mmHg.
Choice A rationale:
PaO2 (partial pressure of oxygen in arterial blood) of 80 mmHg indicates that the oxygen therapy has been effective. Normal PaO2 levels range from 75 to 100 mmHg, so a value of 80 mmHg suggests adequate oxygenation.
Choice B rationale:
SaO2 (arterial oxygen saturation) of 88% is below the normal range (typically 95-100%) and indicates hypoxemia, suggesting that the oxygen therapy has not been fully effective.
Choice C rationale:
A respiratory rate (RR) of 32 breaths per minute is significantly higher than the normal range (12-20 breaths per minute) and indicates respiratory distress, suggesting that the oxygen therapy has not been effective.
Choice D rationale:
Blood pressure (BP) of 160/90 mmHg is elevated and indicates hypertension, which is not a direct measure of the effectiveness of oxygen therapy. This finding does not provide information about the patient’s oxygenation status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is B
Explanation
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.
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