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. Client reporting nasal dryness and discomfort.
Explanation: The client reporting nasal dryness and discomfort indicates inadequate humidification of the oxygen. The nurse should assess and adjust the oxygen flow rate or consider providing humidified oxygen to alleviate the client's discomfort.
Incorrect choices: a. An oxygen saturation of 98% indicates adequate oxygenation and does not necessitate an adjustment in the oxygen flow rate.
b. A respiratory rate of 16 breaths per minute within the normal range does not indicate a need for adjustment of the oxygen flow rate.
d. An oxygen flow rate set at 4 L/min may be appropriate for a Venturi mask, depending on the prescribed oxygen concentration and the client's needs.
Correct Answer is C
Explanation
Answer: c. "Avoid using electric heating devices in your home."
Explanation: Oxygen supports combustion, and using electric heating devices in the presence of oxygen therapy can pose a significant fire hazard. It is important to educate clients with long-term oxygen therapy about the importance of avoiding open flames and electric heating devices to ensure their safety.
Incorrect choices: a. Ensuring a fire extinguisher is readily available is a good general safety practice but may not directly address the specific risk associated with oxygen therapy.
b. Keeping the oxygen tubing loose may increase the risk of tangling and accidental disconnection. The tubing should be appropriately secured and free from obstructions.
d. Using an oxygen concentrator for outdoor activities may not be necessary for all clients and should be based on individual needs and healthcare provider recommendations.
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