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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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.
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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