The nurse is caring for a client receiving oxygen therapy via a Venturi mask. Which assessment finding indicates the need for adjustment of the oxygen flow rate?

Oxygen saturation of 98%.

Respiratory rate of 16 breaths per minute.

Client reporting nasal dryness and discomfort.

Oxygen flow rate set at 4 L/min.

Answer and Explanation

The Correct Answer is C

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.

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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.

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 caring for a client receiving oxygen therapy via a Venturi mask. Which assessment finding indicates the need for adjustment of the oxygen flow rate?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a tracheostomy receiving oxygen therapy. Which intervention should the nurse prioritize to prevent infection and ensure proper oxygen delivery?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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