ATI SM 3.0: Oxygen Therapy With complete verified solutions latest updated version

A nurse should recognize that which of the following is an indication for oxygen therapy?

A. Respiratory rate 32/min; anxiety

B. Dyspnea; PaO2 90 mmHg

C. Chest pain; FiO2 65% for 4 days

D. Tachypnea; SaO2 90%

D. Tachypnea; SaO2 90%

Rationale:

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%.

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

A. Clean the mask with soapy water every other day

B. Reposition the elastic band frequently

C. Apply petroleum jelly around and inside the nares

D. Make sure there is adequate condensation in the tubing

B. Reposition the elastic band frequently

Rationale:

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. General recommendations are to rinse the mask with clear, warm water every 4 to 8 hr as needed

C. Protecting the nares is important, but water-based lubricant is recommended. Oxygen has a high combustion potential, and petroleum products are technically combustible as well. Also, for patients who use a nasal cannula, petroleum jelly can clog its openings.

D. Condensate in oxygen-delivery tubing can block the flow of oxygen to the patient. It must be drained into a separate container, not into the humidifier (where any bacteria in the condensate could become aerosolized).

Administering oxygen therapy with a nonrebreather mask has which of the following advantages?

A. Offers the highest oxygen concentration of the low-flow systems

B. Provides oxygen concentrations of 40%-60%

C. Incorporates a design that requires minimal monitoring of the patient

D. Is designed for safety once the mask's valves and flaps are sealed

A. Offers the highest oxygen concentration of the low-flow systems

Rationale:

A nonrebreather mask delivers oxygen concentrations of 60% to 80%. it provides a higher fraction of inspired oxygen (FiO2) than nasal cannula (also low-flow, delivering about 24% - 44%) or a simple mask (low-flow, delivering 40% - 60%)

Incorrect rationales:

B. Depending on the patient's breathing pattern, a nonrebreather mask can deliver oxygen concentrations of 60% to 80%

C. Patients must be monitored closely because deflation of the reservoir bag (from which the patient draws all inspired oxygen) decreases oxygen delivery.

D. The design of the mask allows expired air to escape during inhalation but prevents inhalation of room air. So, if the oxygen source malfunctions or is depleted and the valves and flaps are sealed, the patient would be unable to breathe room air.

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?

A. Simple face mask

B. Nasal cannula

C. Venturi mask

D. Face tent

C. Venturi mask

Rationale:

Venturi mask most often used for critically ill patients who require administration of specific concentration of O2

Incorrect rationales:

A. Simple mask is usually used for patients who require a moderate flow rate for a short period of time. Because it fits loosely, the oxygen concentration varies.

B. Exact concentration of oxygen inspired through a nasal cannula depends on the flow rate and on the patient's rate and pattern of breathing and depth of respiration. This device cannot ensure delivery of a specific concentration of oxygen.

D. A face tent is convenient for delivering both humidification and oxygen; however, it is difficult to control the concentration of oxygen administered since it depends on the rate and depth of the patient's respirations.

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?

A. Elevated blood pressure

B. Decreased respiratory rate

C. Cyanosis

D. Peripheral edema

A. Elevated blood pressure

Rationale:

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.

Incorrect rationales:

B. A declining respiratory rate is a common finding in the late stages of hypoxia. In the early stages, vital-sign changes include increases in the heart and respiratory rates.

C. Cyanosis, a bluish discoloration of the skin and mucous membranes, is a common finding in the late stages of hypoxia.

D. Peripheral edema is a sign of chronic hypoxia, such as that experienced by patients with long-standing COPD.

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?

A. Respiratory rate 14/min

B. SaO2 90%

C. Cardiac output 5.6L/min

D. PaCO2 68 mm Hg

A. Respiratory rate 14/min

Rationale:

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.

Incorrect rationale:

B. The normal range for arterial oxygen saturation is 95% to 100%, thus this level indicates hypoxemia

C. Although this is a normal cardiac output (pulse rate multiplied by stroke volume), this parameter does not provide information to support the effectiveness of oxygen therapy. A low cardiac output, however, can interfere with oxygenation of body tissues and can be an indication for oxygen therapy

D. This is abnormally high arterial carbon dioxide level&, depending on patient's clinical condition, may indicate need for adjustment or discontinuation of O2 therapy.

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

A. Starts the flow of oxygen

B. Provides the maximal oxygen flow

C. Provides a minimal oxygen flow

D. Stops the flow oxygen

D. Stops the flow oxygen

Rationale:

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.

Incorrect rationales:

A. Turning the knob on the flow meter to the left begins the flow of oxygen from the oxygen cylinder to the patient.

B. Turning the knob on the flow meter all the way to the left provides the maximal oxygen flow.

C. Starting at the off position, turning the knob on the flow meter slightly to the left provides a minimal oxygen flow.

A nurse is caring for a patient who has tracheostomy. Which of the following must the nurse use when administering oxygen to this patient?

A. Distilled water for humidification

B. A tracheotomy collar

C. An inner tracheostomy cannula

D. An aerosol mask

B. A tracheotomy collar

Rationale:

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.

Incorrect rationales:

A. Sterile water, not distilled water, is used for humidification.

C. An inner cannula is a piece of equipment that fits inside the outer cannula of a double-lumen tracheostomy tube and locks into place. It is essential for the use of some types of respiratory equipment, but oxygen can be delivered via single-lumen tubes as well

D. Aerosol masks, used when high humidity levels are required, fit over the patient's mouth and nose, not over a tracheostomy.

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?

A. Assessment

B. Diagnosis

C. Planning

D. Evaluation

B. Diagnosis

Rationales:

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

Incorrect rationales:

A. During the assessment phase, the nurse collects and verifies data to formulate a database reflecting the patient's problems and concerns.

C. During the planning phase, the nurse determines patient outcomes, establishes priorities, and identifies nursing interventions.

D. During the evaluation phase, the nurse determines whether or not the planned patient outcomes have been met and revises the plan of care if indicated.

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?

A. Poor skin turgor

B. Copious respiratory secretions

C. Cracks in oral mucosa

D. Elevated heart rate

C. Cracks in oral mucosa

Rationale:

Oxygen, especially when delivered long-term and/or without sufficient humidification, is extremely drying and can cause cracks in the nasal and oral mucosa.

Incorrect rationales:

A. Poor skin turgor reflects dehydration, which is not a typical adverse effect of oxygen therapy.

B. Pulmonary secretions are not an adverse effect of oxygen therapy but more likely related to the problem for which the patient was prescribed oxygen therapy (pneumonia).

D. Tachycardia, caused by a wide variety of clinical conditions including hypoxia, generally increases the body's demand for oxygen, but it is not an adverse effect of oxygen therapy.

A patient who is in prescribed oxygen therapy 24hr/day is concerned about being confined to bed. Which of the following should the nurse do to provide mobility for this patient?

A. Suggest rest periods between activities of daily living

B. Allow the patient to remove the oxygen-delivery device periodically

C. Make sure the patient has up to 50 feet of connecting tubing

C. Make sure the patient has up to 50 feet of connecting tubing

Rationale:

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.

Incorrect rationales:

A. Rest periods can help prepare patients for periods of increased mobility and also for recovery from periods of increased mobility. But rest does not provide increased mobility.

B. This would violate the provider's order for oxygen delivery 24 hr/day.