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 D
This respiratory care scenario requires applying knowledge of oxygen delivery systems and normal physiological responses. To answer correctly, the nurse must understand the mechanical function of a partial rebreather mask and recognize the significance of a normal adult respiratory rate during therapy.
Choice A rationale: Increasing the oxygen liter flow is unnecessary because the reservoir bag is already functioning correctly by not deflating completely. Liter flow for this mask must be high enough (typically 6 to 11 L/min) to keep the bag two-thirds full.
Choice B rationale: Encouraging deep breaths is not indicated as the client's respiratory rate of 14 breaths/minute is within the normal adult range of 12 to 20 breaths/minute. The current breathing pattern is effectively facilitating oxygenation without the need for coaching.
Choice C rationale: Removing the mask would interrupt oxygen therapy and is contraindicated. The reservoir bag is supposed to remain partially inflated during inhalation to ensure the client receives the prescribed oxygen concentration rather than room air or exhaled carbon dioxide.
Choice D rationale: The reservoir bag of a partial rebreather mask should not deflate completely during inspiration to prevent carbon dioxide buildup. Since the bag is functioning normally and the respiratory rate is stable, the nurse should simply document these findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Giving water may be necessary, but it is not the first intervention if there is a concern about urinary output.
Choice B reason: Notifying the healthcare provider is important but should occur after initial assessments and interventions.
Choice C reason: Checking for a kink in the drainage tubing is a quick and simple intervention that may resolve the issue of low output.
Choice D reason: Reviewing the intake and output record is important for understanding the patient's fluid status but is not the first action to take in this situation.
Correct Answer is B
Explanation
Choice A reason: While fitting for an N95 mask is important, it is not required for droplet precautions, which are appropriate for meningococcal infections.
Choice B reason: For meningococcal infections, droplet precautions, including a standard face mask, are recommended for the first 24 hours of antimicrobial therapy.
Choice C reason: It is the responsibility of the healthcare facility to ensure that all staff members who require it are fitted for particulate filter masks, but this does not apply to droplet precautions for meningococcal infections.
Choice D reason: Sending the UAP for an immediate fitting for a particulate filter mask is unnecessary for droplet precautions and could delay essential care for the client.
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