The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the client’s needs?
Partial non-rebreathing mask
Simple (Oxy Plus) mask
Nasal cannula
Non-rebreathing mask
The Correct Answer is C
A. Partial non-rebreathing mask:
This mask delivers higher concentrations of oxygen than a nasal cannula. It has a reservoir bag that allows the client to rebreathe some exhaled air, increasing the oxygen concentration delivered. However, it may not be necessary for a client with mild shortness of breath and slightly reduced oxygen saturation.
B. Simple (Oxy Plus) mask:
The simple mask provides a higher concentration of oxygen than a nasal cannula but lacks the reservoir bag found in the non-rebreathing mask. It is generally used for moderate oxygen needs. However, it might be more than what is required for a client with mild shortness of breath and slightly reduced oxygen saturation.
C. Nasal cannula:
Nasal cannulas are commonly used for clients with mild respiratory distress. They deliver a lower to moderate concentration of oxygen and are well-tolerated by most clients. They are suitable for individuals with mild shortness of breath and can be adjusted based on the required flow rate.
D. Non-rebreathing mask:
The non-rebreathing mask provides the highest concentration of oxygen among the options listed. It includes a reservoir bag to deliver a higher oxygen concentration. It is typically reserved for clients with higher oxygen requirements. For a client with mild shortness of breath and slightly reduced oxygen saturation, this may be more than necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Coronary artery disease (CAD):
Coronary artery disease primarily affects the blood vessels supplying the heart muscle. Symptoms often include chest pain (angina) rather than pain in the lower extremities. The symptoms described in the scenario are not characteristic of CAD.
B. Arterial embolus:
An arterial embolus is a blood clot or debris that travels through the bloodstream and can block an artery. While it can cause decreased blood flow and pain, the presentation in the lower left leg and foot with relief of pain at rest is more suggestive of peripheral arterial disease (PAD) or intermittent claudication rather than an acute arterial embolus.
C. Raynaud disease:
Raynaud's disease is characterized by episodes of reduced blood flow to the extremities, usually triggered by cold or stress. It typically involves color changes (white, blue, red) in the fingers or toes. The symptoms described, including pain in the lower leg and foot during walking, are not typical of Raynaud's disease.
D. Intermittent claudication:
Intermittent claudication is a symptom associated with peripheral arterial disease (PAD). It involves pain or cramping in the legs during physical activity, such as walking, due to reduced blood flow to the muscles. Rest typically relieves the pain. The observation of a hairless leg and slight edema suggests potential vascular compromise in the lower extremity, supporting the diagnosis of intermittent claudication.
Correct Answer is B
Explanation
A. International normalized ratio (INR):
INR is a test used to monitor the effectiveness of anticoagulant therapy, particularly drugs like warfarin. It measures the time it takes for blood to clot. It's not directly related to assessing heart failure but is more associated with monitoring anticoagulation status.
B. Brain natriuretic peptide (BNP):
BNP is a peptide released by the heart in response to increased pressure and volume in the heart, often seen in heart failure. Elevated BNP levels can indicate the presence of heart failure. It's a useful diagnostic marker for heart failure.
C. Troponin:
Troponin is a protein released into the blood when there is damage to the heart muscle, usually during a heart attack. It is not specific to heart failure but is commonly used to diagnose myocardial infarction (heart attack).
D. Creatinine:
Creatinine is a waste product that comes from the normal wear and tear on muscles. While elevated creatinine levels can be seen in conditions affecting kidney function, it's not a direct marker for assessing heart failure. However, kidney function is often evaluated in conjunction with heart failure assessments.
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