Oxygen Therapy

Skills Module 3.D: Oxygen Therapy Posttest Question: 1 of 11 А nurse is caring for а client who has а tracheostomy. Which of the following pieces of equipment should the nurse use when administering oxygen to this client? (_ Distilled water for humidification INCORRECT Sterile water. not distilled water, is used for humidification. (о) А tracheosromy collar CORRECT А tracheostomy collar is а piece of equipment that fits over the tracheostomy site and is held in place Ьу an adjusraЫe elastic strap that fits around the client's neck. The collar provides the client with the prescribed oxygen concentration while also providing high humidity. С, А nasal cannula INCORRECT А nasal cannula has prongs that fit inside the client's nose to deliver oxygen. А nasal cannula is not used for а tracheostomy. An aerosol mask INCORRECT Aerosol masks, used when high humidity levels are required, fit over the client's mouth and nose, not over а tracheosюmy. Question: 2 of 11 А nurse is caring for а client who has been receiving oxygen via nasal cannula for 4 hr. Which of the following assessment findings helps indicate that oxygen therapy has been effective? (., Respirarory rate 14/m,n CORRECT The expected reference range for respirations is 12 to 20/min. Stabllization of the respiratory rate, especially if the client was previously tachypneic, is an indication that oxygen therapy is effective. '-.../ Sa02 90% INCORRECT The expected reference range for Sa02 is 95% to 100%. Therefore, this level indicates hypoxemia. С Cardiac output 5.6 L/min INCORR.ECT Although this is an expected cardiac output (pulse rate multiplied Ьу stroke volume), this parameter does not provide information to support the effectiveness of oxygen therapy. However, а low cardiac output can interfere with oxygenation of body tissues and can Ье an indication for oxygen therapy. РаСО 2 68 mm Hg INCORRECT This is an abnormally high arterial carbon dioxide level and, depending on the client's clinical condition, might indicate the need for an adjustment ог discontinuation of oxygen therapy. Question: З of 11 А home health nurse is teaching а client who has just started receiving oxygen therapy via mask. The nurse should emphasize that the client must clean the mask with soapy wate,· опсе every other day INCORRECT General recommendations are to rinse the mask with clear, warm water every 4 to 8 hr as neededl reposItIon the elastic band frequently. CORRECT Tubing and elastic bands that are part of oxygen-delivery devices can cause pressure on the skin that can lead to breakdown. Padding them and frequently changing their position can help prevent this complication. С apply petroleum jelly around and inside the nares. INCORRECT Protecting the nares is important, but а water-based lubricant is recommended. Oxygen has а high combustion potential and petroleum products are combustiЫe as well. Furthermore, for clients who use а nasal cannula: petroleum jelly can clog its openings. r make sure there is adequate condensation in the шbing. INCORRECT Condensate in oxygen-delivery tublng can Ыосk the flow of oxygen to the client. lt must Ье drained into а separate container, not into the humidifier, which could result in bacteria in the condensate to become aero�olized. Question: 4 of 11 Oxygen therapy is prescribed for а client who is brought to ап emergency department in the early stages of hypoxia. When assessing this client. а nurse should expect which of the following findings? ( Elevated Ыооd pressure CORRECT During the early stages of hypoxia, Ыооd pressure is usually elevated (unless shock is the cause of the c\ient's hypoxia). ln the late stages of hypoxia, clients are likely to develop hypotension. с=) Decreased respiratory raie INCORRECT А declining respiratory rate is а common finding in the late stages of hypoxia. ln the early stages, vital sign changes include increases in both the heart and respiratory rates. С Cyanosis INCORRECT Cyanosis, а Ьluish discoloration of the skin and mucous membranes caused Ьу low oxygen levels in the Ыооd, is а common finding in the late stages of hypoxia. (; Peripheral edema INCORRECT Peripheral edema is а sign of chronic hypoxia, which is experienced Ьу clients who have long-standing COPD. Question: 5 of 11 А nurse is caring for а critically ill client who has COPD and requires delivery of а precise concentration of oxygen. Which of the following types of oxygen-delivery devices is indicated for this client? С Simple face mask INCORRECT А simple mask is usually used for clients who require а moderate flow rate for а shorr period of time. Because а simple face mask fits loosely, the oxygen concenrration varies. Nasal cannula INCORRECT The exact concentration of oxygen inspired through а nasal cannula depends on the flow rate and on the client's rate and pattern of breathing and depth of respiration. This device cannot ensure delivery of а specific concentration of oxygen. С Venшri mask CORRECT А Venturi mask is most often used for critically ill clients who require administration of а specific concentration of oxygen. This is the most accurate form of oxygen delivery and keeps carbon dioxide buildup minimal. '-../ Face tent INCORRECT А face tent is convenient for delivering both humidification and oxygen; however, it is difficult to control the concentration of oxygen administered because it depends оп the rate and depth of the client's respirations. Question: б of 11 А nurse is providing discharge teaching to а client who will continue oxygen therapy at ,home. The nurse should instruct the client that turning the knob оп the oxygen flow meter all tl)e way to the right starrs the flow of oxygen. INCORRECT Turning the knob on the flow meter to the left begins the fiow of oxygen from the oxygen cylinderlto the client. С provides the maximal oxygen flow. INCORRECT Turning the knob оп the flow meter all the way to the left provides the maximal oxygen flow. provides а minimal oxygen flow. INCORRECT Starting at the off position, turning the knob оп the fiow meter slightly to the left provides а minimal oxygen flow. О stops the flow of oxygen. CORRECT Turning the knob on the flow meter all the way to the right allows no oxygen to flow from the oxygen cylinder to the client. Question: 7 of 11 А nurse is caring for а client who has dyspnea, slight cyanosis, and а respiratory rate of 28/min. During which of the following phases of the nursing process will the nurse determine that the client has impaired gas exchange? Assessment INCORRECT During the assessment phase, the nurse collects and verifies data to formulate а database reflecting the client's proЫems and concerпs. Diagnosis CORRECT During the diagnosis phase, the nurse analyzes and interprets data gathered from the nursing assessment to formulate а nursing diagnosis, which in this case is impaired gas exchange. Planning INCORRECT During the planning phase, the nurse determines client outcomes, estaЫishes priorities, and identifies nursing interventions. J Evaluation INCORRECT During the evaluation phase. the nurse determines whether the planned client outcomes have Ьееп met and revises the plan of care if indicated. Question: 8 of 11 А nurse is providing discharge teaching with а client who is going home оп continuous liquid oxygen therapy. Which of the following instructions should the nurse include? ../ "Place the oxygen tank In а clutter-free environment. CORRECT The nurse should instruct the client to place the oxygen-delivery system in а clutter-free environment that is well ventilated. This prevents injuries from improper placement of the oxygen equipment. "Кеер the oxygen tank at least 6 feet away from а hear source." INCORRECT The nurse should instruct the client to keep the oxygen rank at least 1 О feet from а heat source (such as an open flame candle ог fireplace) because oxygen can ignite as а result of the heat, causing а fire. r "Ensure you are close ro electпcity ю use your oxygen tank." INCORRECT The nurse should instruct the client that electricity is required for oxygen concentrators, not liquid oxygen therapy. '::::: "Turn the valve оп the oxygen tank until an alarm sounds. INCORRECT The nurse should instruct the client that ап alarm on the oxygen tank will sound when the tank is almost empty. Question: 9 of 11 Administering oxygen therapy with а nonrebreather mask has which of the following advantages? Offers !he highes! oxygen concen1ra1ion of !he low-flow sys1ems CORRECT А nonrebreather mask delivers oxygen concentrations of 60% to 80%. Thus, it provides а higher fraction of inspired oxygen (Fi0 2 ) than other low-flow systems such as а nasal cannula (delivering аЬощ 24% to 44%) or а simple mask (delivering 40% 10 60%). � Provides oxygen concen1ra1ions of 40% to 60% INCORRECT Depending оп the client's breathing pattern, а nonrebreather mask сап deliver oxygen concentratjons of 60% to 80%. v 1ncorpora1es а des1gn tha! requires min1mal mon1toring of the client INCORRECT Clients who are receiving oxygen through а nonrebreather mask need to Ье monitored closely because deftation of the reservoir bag (from which the client draws all inspired oxygen) decreases oxygen delivery and сап cause !he clien! to breathe exhaled carbon dioxide, resul1ing in risk to the client. (_, 1s designed for safe1y once the mask's valves and flaps are sealed INCORRECT The design of the mask allows expired air to escape during inhalation but prevents inhalation of room air. So, if !he oxygen source malfunctions or is depleted and the valves and flaps are sealed, the client would Ье 1 uпаЫе to breathe room air. Question: 10 of 11 А nurse should recognize that which of the following findings is ап indication for oxygen therapy? Г'- Respiraшry rate 32/min INCORRECT А client who has а respiratory гаtе of 32/min is outside the expected reference range of 12 to 20/min. The client is hyperventilating and does not require more охуgеп but rather needs more carbon dioxide, which can Ье oЬtained Ьу exhaling into апd inhaling from а рарег bag. :: Ра02 90 mm Hg INCORRECT А partial pressure of oxygen is а measurement of oxygen pressure in arterial Ыооd. This indicates how effective охуgеп is moving from the lungs to the Ыооd. А partial pressure of охуgеп of 90 mm Hg is within the expected reference range of 83 to 1 00 mm Hg and does not indicate oxygen therapy is needed. " Fraction of inspired oxygen (Fi02) 65% for 4 days INCORRECT Охуgеп toxicity сап develop when the fraction of inspired охуgеп (Fi02) is above 50% for longer than 24 to 48 hr. One of the early signs of охуgеп toxicity is substernal chest pain. Маге oxygen might further damage the clienrs lungs. С Охуgеп saturation (SaO2) 90% CORRECT Oxygen therapy is indicated for clients who are at risk for or have developed hypoxia. ln the early stages of hypoxia, the heart rate increases апd the arterial oxygen saturation (SaO 2) falls below 94%. Qy.estion: 11 of 11 А nurse is caring for а client who was admitted with community-acquired pneumonia and has been receiving oxygen therapy for several days. Which of the following findings indicates an adverse effect of oxygen therapy? Poor sk1n turgor INCORRECT Poor skin turgor reflects dehydration. which is not ап adverse effect of oxygen therapy. Copюus respIratory secretюns INCORRECT Pulmonary secretions are not ап adverse effect of oxygen therapy and are more likely related to t�e pneumonia for which the client was prescribed oxygen therapy. � Cracks in the oral mucosa CORRECT Oxygen, especially when delivered long-term and withour sufficient humidification, has а drying effect that сап cause cracks in the nasal and oral mucosa. '-,/ Elevated heart rate INCORRECT Tachycardia, caused Ьу а wide variety of clinical conditions, such as hypoxia, generally increases the body's demand for oxygen. However, it is not an adverse effect of oxygen therapy.