When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

Assess the position of the mask on the client's face.

Release and reinsert the flowmeter in the wall outlet.

Attach the flowmeter to a humidification canister.

Adjust the flow rate to the prescribed liters per minute.

Answer and Explanation

The Correct Answer is B

Choice A reason: Assessing the position of the mask on the client's face is not the priority action. The mask may be well-fitted, but the oxygen delivery may be compromised by the faulty connection of the flowmeter.

Choice B reason: Releasing and reinserting the flowmeter in the wall outlet is the best action as it may correct the problem of the loose or misaligned connection. The nurse should ensure that the flowmeter is securely attached and that the oxygen is flowing properly.

Choice C reason: Attaching the flowmeter to a humidification canister is not necessary for oxygen delivery per mask. Humidification is usually added for high-flow oxygen devices such as nasal cannula or face tent.

Choice D reason: Adjusting the flow rate to the prescribed liters per minute is not the appropriate action. The flow rate may be correct, but the oxygen delivery may be impaired by the hissing sound indicating a leak or obstruction.

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Correct Answer is C

Explanation

Choice A reason: Removing the nasal cannula is not appropriate as it would deprive the client of supplemental oxygen. The client's oxygen saturation is below the normal range of 95% to 100%, indicating hypoxemia.

Choice B reason:While increasing oxygen might seem appropriate, this should only be done after verifying the accuracy of the pulse oximeter reading and assessing the client’s overall condition. Automatically increasing oxygen without further assessment could delay addressing other underlying issues or lead to over-oxygenation in clients with certain conditions like COPD.

Choice C reason:The first step is to ensure the accuracy of the pulse oximeter reading by checking its placement and ruling out factors that can interfere with accurate readings, such as poor circulation, cold extremities, nail polish, or motion artifacts. This ensures that the subsequent intervention is based on reliable data.

Choice D reason: Switching to a non-rebreather mask is not necessary as it would deliver a high concentration of oxygen (up to 100%) that may be excessive for the client. A nasal cannula can deliver oxygen from 1 to 6 L/minute, depending on the client's needs.

A. Complete an adverse occurrence/incident report. B. Demonstrate proper securing of the restraints. C. Ensure that the restraints are not too tight. D. Initiate the facility's restraint flow sheet.

Correct Answer is B

Explanation

Choice A reason: Completing an adverse occurrence/incident report is not the most important action to implement. It may be necessary to document the incident later, but it does not address the immediate safety issue of the client.

Choice B reason: Demonstrating proper securing of the restraints is the best action to implement. It corrects the mistake made by the UAP and ensures that the client is not at risk of injury or entrapment. It also educates the UAP on the correct technique and policy for applying restraints.

Choice C reason: Ensuring that the restraints are not too tight is a relevant action to implement, but not the most important one. It is part of the ongoing assessment and care of the client who is restrained, but it does not correct the improper securing of the restraints to the bedside rails.

Choice D reason: Initiating the facility's restraint flow sheet is a required action to implement, but not the most important one. It is part of the documentation and evaluation of the client who is restrained, but it does not address the immediate safety issue of the client.

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When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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