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.
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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Related Questions
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.
Correct Answer is C
Explanation
Answer: c. Applying a sterile dressing over the tracheostomy site.
Explanation: Applying a sterile dressing over the tracheostomy site helps prevent infection by providing a barrier against microorganisms. It also ensures a clean environment for optimal oxygen delivery and promotes wound healing.
Incorrect choices: a. Regularly suctioning the tracheostomy tube is important for maintaining airway patency but may not directly address infection prevention or oxygen delivery.
b. Assessing the client's respiratory rate every hour is important for monitoring respiratory status but does not specifically address infection prevention or oxygen delivery.
d. Administering humidified oxygen through the tracheostomy tube may be necessary to provide moistened air to the client's lungs but does not directly address infection prevention.
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