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.
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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Related Questions
Correct Answer is B
Explanation
Answer: b. Disconnect the tubing and drain the condensation.
Explanation: Condensation in the oxygen tubing can impede the flow of oxygen and reduce the effectiveness of oxygen therapy. The nurse should disconnect the tubing and drain the condensation before reconnecting and continuing oxygen therapy.
Incorrect choices: a. Increasing the oxygen flow rate does not address the issue of condensation and may lead to unnecessary oxygen supplementation.
c. Replacing the oxygen tubing with a new one immediately may not be necessary if the condensation can be resolved by draining it.
d. Placing a heat-moisture exchanger (HME) on the oxygen tubing is not necessary for managing condensation but can be used to provide humidification for clients receiving high-flow oxygen therapy.
Correct Answer is D
Explanation
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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