A nurse is caring for a client who has dyspnea with an oxygen saturation of 88%. Which of the following indicates the type of face mask the nurse should use to deliver the client a 90% oxygen concentration?

Simple face mask

Nasal prongs

Non-rebreather mask

Nasal cannula

Answer and Explanation

The Correct Answer is C

A. Simple face mask: This can deliver oxygen at flow rates of 5-10 liters per minute and typically provides an oxygen concentration of about 35-50%.

B. Nasal prongs: Nasal prongs deliver oxygen at lower flow rates and may not be sufficient to raise the client's oxygen saturation to 90%.

C. Non-rebreather mask: This mask can deliver high concentrations of oxygen (up to 90-100%) at flow rates of 10-15 liters per minute. It has one-way valves to prevent the patient from rebreathing exhaled air, thus maximizing the delivery of oxygen.

D. Nasal cannula: Nasal cannulas deliver oxygen at lower flow rates (typically up to 6 liters per minute) and may not provide the necessary concentration to achieve an oxygen saturation of 90%.

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Correct Answer is C

Explanation

A. Applying talc powder around the stoma can prevent the appliance from adhering properly, leading to leakage. It is not recommended for ostomy care.

B. The skin barrier should be cut to fit closely around the stoma, leaving no more than a 1/8 inch gap, not 1/2 inch. A larger opening may cause skin irritation or leakage.

C. Pressing on the skin barrier for about 30 seconds ensures that it adheres properly to the skin, which helps secure the ostomy appliance and prevents leakage.

D. Moisturizing soap is not recommended for cleaning around the stoma, as it can leave a residue that interferes with the appliance's adhesion. Mild soap without moisturizers or just water should be used.

A. Severe wheezing B. Rhinitis C. Small, raised vesicles over the body D. Itching of the skin

Correct Answer is A

Explanation

A. Severe wheezing indicates a potential allergic reaction or anaphylaxis to the IV antibiotics, which requires immediate intervention. It can compromise the client's respiratory function and may lead to respiratory arrest if not promptly addressed.

B. Rhinitis, or inflammation of the nasal passages, is not typically associated with IV antibiotic administration and is not a life-threatening emergency.
C. Small, raised vesicles over the body may indicate a rash or allergic reaction, but unless accompanied by other severe symptoms such as difficulty breathing or systemic signs of anaphylaxis, it does not require immediate reporting.
D. Itching of the skin may indicate a mild allergic reaction, but unless accompanied by more severe symptoms, it does not require immediate reporting.

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A nurse is caring for a client who has dyspnea with an oxygen saturation of 88%. Which of the following indicates the type of face mask the nurse should use to deliver the client a 90% oxygen concentration?

Nursing Test Bank

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