The nurse is assessing a client who is receiving high-flow oxygen therapy via a non-rebreather mask. Which finding requires immediate intervention?

Oxygen flow rate of 10 L/min.

Oxygen saturation of 95%.

Presence of condensation in the mask.

Loose fit of the mask on the client's face.

Answer and Explanation

The Correct Answer is D

Answer: d. Loose fit of the mask on the client's face.

Explanation: A loose fit of the mask on the client's face can result in a significant reduction in the delivery of high-flow oxygen therapy. It is essential to ensure a proper seal and fit of the mask to maximize the effectiveness of oxygen therapy. Immediate intervention is needed to readjust and secure the mask properly.

Incorrect choices: a. An oxygen flow rate of 10 L/min may be appropriate for high-flow oxygen therapy, depending on the client's condition and prescribed treatment.

b. An oxygen saturation of 95% indicates adequate oxygenation and is within the target range for most clients.

c. Condensation in the mask can be managed by draining it appropriately and does not necessarily require immediate intervention unless it significantly obstructs oxygen flow.

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Correct Answer is C

Explanation

Answer: c. Padding the pressure points on the client's face with soft material.

Explanation: Oxygen masks, especially those that exert pressure on specific areas of the face, can cause skin breakdown and pressure ulcers. Padding the pressure points with soft material helps distribute the pressure more evenly and reduces the risk of skin damage.

Incorrect choices: a. Changing the position of the mask every 2 hours is important for preventing pressure ulcers related to prolonged pressure on the skin but may not directly address the pressure points created by the mask.

b. Applying a protective barrier cream to the client's face is not specifically indicated for preventing pressure ulcers caused by oxygen masks. It is more commonly used for preventing moisture-associated skin damage.

d. Encouraging the client to remove the mask intermittently for facial skin care may compromise oxygen delivery and is not recommended unless otherwise specified by the healthcare provider.

A. Assessing the client's respiratory rate every hour. B. Checking the oxygen flow rate every 4 hours. C. Monitoring the client's oxygen saturation continuously. D. Adjusting the oxygen mask snugly on the client's face.

Correct Answer is C

Explanation

Answer: c. Monitoring the client's oxygen saturation continuously.

Explanation: Continuous monitoring of the client's oxygen saturation allows the nurse to assess the effectiveness of oxygen therapy and ensure the prescribed oxygen concentration is being delivered. It helps in making timely adjustments to the oxygen therapy to maintain adequate oxygenation.

Incorrect choices: a. Assessing the client's respiratory rate every hour is important but does not directly ensure the delivery of the prescribed oxygen concentration.

b. Checking the oxygen flow rate every 4 hours is important for monitoring equipment functionality but does not directly ensure the delivery of the prescribed oxygen concentration.

d. Adjusting the oxygen mask snugly on the client's face is important for proper fit and oxygen delivery, but it does not directly ensure the delivery of the prescribed oxygen concentration.

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The nurse is assessing a client who is receiving high-flow oxygen therapy via a non-rebreather mask. Which finding requires immediate intervention?

Nursing Test Bank

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