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An 80-year-old male patient has been admitted to the acute care facility with the diagnosis of pneumonia. He is receiving oxygen via nasal cannula at 2 L/min. The nurse assesses respirations at 24/min PaO2 level 88 mm Hg and pink skin tone. What action should the nurse implement?
- A. Notify the health care provider.
- B. Increase oxygen to 4 L/min.
- C. Record PaO2 level.
- D. Administer nebulizer treatment.
Correct Answer: C
Rationale: The nurse would document PaO2 level. Normal arterial oxygen levels sometimes decrease with age, but not usually low enough to fall outside the normal range. It may be possible for an 80-year-old person to have an arterial partial pressure oxygen (PaO2) level (the amount of oxygen found in the arterial circulation) between 80 and 85 mm Hg (normal range is 80 to 100 mm Hg) without experiencing significant alterations in health.
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What is the appropriate value for the Venturi mask? Oxygen delivery devices with percent of oxygen delivered
- A. 1-6 L/min = 24%-44% O2
- B. 5-8 L/min = 35%-55% O2
- C. 4-10 L/min = 24%-55% O2
- D. 6-12 L/min = 60%-90% O2
- E. 6-15 L/min = 70%-100% O2
Correct Answer: C
Rationale: Venturi mask delivers 4-10 L/min = 24%-55% O2, as per the table: Nasal cannula (1-6 L/min = 24%-44% O2), Simple face mask (5-8 L/min = 35%-55% O2), Venturi mask (4-10 L/min = 24%-55% O2), Partial rebreather mask (6-12 L/min = 60%-90% O2), Nonrebreather mask (6-15 L/min = 70%-100% O2).
A patient has a new health care provider's order for oxygen administration at 2 L via nasal cannula. Who can initiate implementation of this order?
- A. RN
- B. UAP
- C. Respiratory therapist
- D. EMT
- E. Nutritional specialist
Correct Answer: A,C,D
Rationale: Oxygen therapy may be initiated by a respiratory therapist, a nurse, an emergency medical technician (EMT), or any other licensed health care provider with an appropriate order for the oxygen. In some facilities, there is a respiratory care department, staffed by respiratory therapists who assume the responsibility of administering oxygen and delivering treatments that will improve a patient's ventilation and oxygenation. Adjustment of the oxygen flow rate is not delegated to UAP nor nutritional specialist.
The wife of a patient with a cuffed tracheostomy asks why the cuff is inflated intermittently. What is the purpose of the inflated cuff?
- A. Prevent regurgitation after meals.
- B. Hold the trachea open until it is completely healed.
- C. Dilate the tracheal opening for passage of secretions.
- D. Prevent aspiration when eating.
Correct Answer: D
Rationale: The cuff is inflated to prevent aspiration while eating or when cleaning the tracheostomy tube.
The nurse is caring for a patient with an endotracheal tube. What interventions will the nurse implement?
- A. Change or clean all respiratory therapy equipment every 24 hours.
- B. Turn and reposition the patient every 2 hours.
- C. Provide constant airway humidification.
- D. Encourage intake of fruits and vegetables.
- E. Elevate the head of the bed.
Correct Answer: B,C,E
Rationale: Nursing interventions for the patient with an endotracheal tube include turning and repositioning every 2 hours for maximal ventilation and lung expansion, constant airway humidification and elevation of the head of the bed to assist with ventilation. Equipment should be changed or cleaned at least every 8 hours. Patients with endotracheal tubes are allowed nothing by mouth (NPO). It is necessary to provide parenteral or enteral nourishment.
When an older adult patient with chronic emphysema comes to the emergency department in respiratory distress at what rate should the nurse begin oxygen per nasal cannula?
- A. 2 L/min
- B. 3 L/min
- C. 4 L/min
- D. 5 L/min
Correct Answer: A
Rationale: Administering O2 at more than 2 L/min to a person with chronic pulmonary disease may cause respiratory failure.