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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: The nurse cannot force the client to take medication against their will, even if it is a controlled substance.

Choice B reason: Crediting the medication back and placing it in the client's medication box is not appropriate as the medication has already been removed from the unit dose wrapper.

Choice C reason: Keeping the medication to see if the client will want to take it later is not safe practice as it could lead to medication errors or misuse.

Choice D reason: The nurse should dispose of the medication properly, and having another nurse witness the disposal is a standard procedure to ensure that controlled substances are accounted for.

A. Complete the intermittent suction of the nasopharynx. B. Apply an oxygen mask over the client's nose and mouth. C. Reposition the pulse oximeter clip to obtain a new reading. D. Stop suctioning until the pulse oximeter reading is above 95%.

Correct Answer is A

Explanation

Choice A reason: If the oxygen saturation remains stable during the procedure, it indicates that the suctioning is not adversely affecting the client's oxygenation, and the nurse can safely continue.

Choice B reason: Applying an oxygen mask is not necessary if the oxygen saturation is stable and within a safe range.

Choice C reason: Repositioning the pulse oximeter clip is only necessary if there is a concern about the accuracy of the reading, not when the reading is stable.

Choice D reason: There is no need to stop suctioning if the oxygen saturation is stable at 94%, as this is within the acceptable range for most clients.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?

Correct Answer is D

Explanation

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

Correct Answer is A

Explanation

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