The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?
Increase the liter flow of oxygen.
Encourage the client to take deep breaths.
Remove the mask to deflate the bag.
Document the assessment data.
The Correct Answer is A
Choice A reason: If the oxygen reservoir bag of a partial rebreather mask does not deflate completely during inspiration, it may indicate that the flow rate is too low. Increasing the liter flow ensures adequate delivery of oxygen.
Choice B reason: Encouraging the client to take deep breaths is beneficial for overall respiratory function but will not address the issue of the reservoir bag not deflating properly.
Choice C reason: Removing the mask to deflate the bag is not a standard practice and could interrupt the delivery of oxygen to the client.
Choice D reason: Documentation of the assessment data is important, but the nurse must first address the issue with the oxygen delivery system to ensure the client is receiving the proper amount of oxygen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Skin turgor is a method to assess hydration status, but it is not the most accurate indicator of fluid balance in a patient with fluid volume overload.
Choice B reason: Monitoring weight is the most accurate method to assess fluid balance. A sudden increase or decrease in weight is indicative of fluid changes.
Choice C reason: Blood pressure can be affected by fluid volume changes, but it does not provide a direct measure of fluid balance.
Choice D reason: Lung sounds can indicate fluid overload in the lungs but do not give a complete picture of overall fluid balance.
Correct Answer is B
Explanation
Choice A reason: Praising the UAP for using standard precautions is not appropriate in this situation as using the same gloves for multiple clients breaches infection control protocols.
Choice B reason: The nurse should instruct the UAP to change gloves immediately to prevent cross-contamination between clients.
Choice C reason: While scheduling an in-service program on asepsis is beneficial for long-term education, it does not address the immediate risk of infection.
Choice D reason: Submitting an adverse occurrence report may be necessary if there is a pattern of non-compliance, but the first action should be to correct the behavior and ensure client safety.
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