ATI – Oxygen therapy
|A nurse should recognize that which of the following is an indication for oxygen therapy?||Tachypnea; SaO2 90%|
Oxygen therapy is indicated for patients who are at risk for or have developed hypoxia. In the early stages of hypoxia, heart rate rises and arterial oxygen saturation (SaO2) falls below 94%.
|Administering oxygen therapy with a nonrebreather mask has which of the following advantages?||Offers the highest oxygen concentration of the low-flow systems|
A nonrebreather mask delivers oxygen concentrations of 60% to 80%. Thus, it provides a higher fraction of inspired oxygen (FiO2) than a nasal cannula (also low-flow, but delivering about 24% to 44%) or a simple mask (low-flow, but delivering 40% to 60%).
|A nurse is caring for a critically ill patient with COPD who requires delivery of a precise concentration of oxygen. Which of the following types of oxygen-delivery device is indicated for this patient?||Venturi mask|
A Venturi mask is most often used for critically ill patients who require administration of a specific concentration of oxygen.
|A nurse is caring for a patient who has a tracheostomy. Which of the following must the nurse use when administering oxygen to this patient?||A tracheostomy collar|
A tracheostomy collar is designed to provide high humidity and the oxygen concentration prescribed for the patient. It is a small oxygen-delivery apparatus that fits over the tracheostomy site and is held in place by an adjustable elastic strap that fits around the patient’s neck.
|A nurse is caring for a patient who is dyspneic and slightly cyanotic, with a respiratory rate of 28/min. The nurse determines that the patient has impaired gas exchange during which of the following phases of the nursing process?||Diagnosis|
During the diagnosis phase, the nurse analyzes and interprets data gathered from the nursing assessment to formulate a nursing diagnosis, in this case, impaired gas exchange.
|A nurse is providing discharge teaching to a patient who will continue oxygen therapy at home. The nurse should instruct the patient that turning the knob on the oxygen flow meter all the way to the right||stops the flow of oxygen.|
Turning the knob on the flow meter all the way to the right allows no oxygen at all to flow from the oxygen cylinder to the patient.
|Oxygen therapy is prescribed for a patient who is brought to an emergency department in the early stages of hypoxia. When assessing this patient, the nurse should expect to find which of the following clinical indicators?||Elevated blood pressure|
During the early stages of hypoxia, blood pressure is usually elevated (unless shock is the cause of the patient’s hypoxia). In the late stages of hypoxia, patients are likely to develop hypotension.
|A patient has been receiving oxygen PRN via nasal cannula for 4 hr. Which of the following assessment findings helps indicate that oxygen therapy has been effective?||Respiratory rate 14/min|
The normal range of respirations is 12 to 20/min. Stabilization of the respiratory rate, especially if the patient was previously tachypneic, is an indication that oxygen therapy is effective.
|A home health nurse is instructing a patient who has just started receiving oxygen therapy via mask. The nurse should emphasize that the patient must||reposition the elastic band frequently.|
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 changing their position often can help prevent this complication.
|A patient who is prescribed oxygen therapy 24 hr/day is concerned about being confined to bed. Which of the following should the nurse do to provide mobility for this patient?||Make sure the patient has up to 50 feet of connecting tubing.|
Patients can use up to 50 feet of connecting tubing to attach the oxygen source to the delivery device. This length of tubing provides the patient with extra mobility.
|A patient admitted with community-acquired pneumonia has been receiving oxygen therapy for several days. Which of the following assessment findings indicates an adverse effect of oxygen therapy?||cracks in the oral mucosa|
Oxygen, especially when delivered long-term and/or without sufficient humidification, is extremely drying and can cause cracks in the nasal and oral mucosa.