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 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.

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Correct Answer is A

Explanation

Choice A reason: An increased boundary of the wound suggests possible infection or inflammation. C-reactive protein (CRP) is an acute-phase reactant produced by the liver in response to inflammation. A CRP test can help assess the severity of inflammation or infection. The normal range for CRP is generally below 10 mg/L.

Choice B reason: While serum potassium and sodium levels are important electrolytes to monitor, they are not directly related to wound assessment or infection. Normal ranges for potassium are 3.6 to 5.2 mmol/L, and for sodium, 135 to 145 mEq/L.

Choice C reason: Neutrophils are white blood cells that respond to infection. While an elevated neutrophil count can indicate infection, it is not as specific as CRP for inflammation. The normal range for neutrophils is 2,500 to 6,000 cells/mcL.

Choice D reason: Platelets are involved in clotting and would not necessarily change due to wound infection or inflammation. The normal platelet count range is 150,000 to 450,000 platelets/mcL.

A. Offer fruit juice at least twice during both the day and evening shifts. B. Encourage the client to eat all of the meals that are sent. C. Lower the bed prior to helping the client to move up in bed. D. Have the client hold a pillow over the abdomen to cough and deep breathe.

Correct Answer is D

Explanation

Choice A reason: Offering fruit juice is part of good nutrition and hydration but does not directly assist with the client's breathing difficulty.

Choice B reason: Encouraging the client to eat all meals is important for nutritional support, but it is not the most critical action related to the client's immediate respiratory comfort.

Choice C reason: Lowering the bed may be a safety measure but does not address the client's need for respiratory support.

Choice D reason: Having the client hold a pillow over the abdomen can help splint the chest while coughing, reducing discomfort and facilitating deep breathing, which is essential for a client with emphysema experiencing difficulty breathing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

Correct Answer is A

Explanation

A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?

Correct Answer is D

Explanation

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