A client is receiving oxygen by nonrebreather mask, but the bag ...

[Lisaclaire]

A client is receiving oxygen by nonrebreather mask, but the bag is deflating on inspiration. What action should be taken by the nurse?
 
  1. Turn the client to the left side.
  2. Increase the percentage of oxygen being delivered.
  3. Check for an airtight seal between the client's face and the mask.
  4. Increase the liter flow of oxygen being delivered.

Question 2

Upon assessment, the nurse notes that a client has dyspnea, crackles in both lung bases, and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details?
 
  1. Ineffective Breathing Pattern
  2. Anxiety
  3. Ineffective Airway Clearance
  4. Impaired Gas Exchange

[ynlevi]

Answer to Question 1

Correct Answer: 4
Rationale 1: There is no need to turn the client to either side.
Rationale 2: All oxygen is delivered at 100, so there is no method to increase the percentage of oxygen being delivered.
Rationale 3: The seal between the client's face and the mask should be snug, but will not be airtight.
Rationale 4: To prevent carbon dioxide buildup, the nonrebreather bag must not totally deflate during inspiration. If it does, the nurse can correct this problem by increasing the liter flow of oxygen.

Answer to Question 2

Correct Answer: 3
Rationale 1: There are no data that support Ineffective Breathing Pattern as a diagnosis.
Rationale 2: There are no data that support Anxiety as a diagnosis.
Rationale 3: The data given for this client best support the nursing diagnosis of Ineffective Airway Clearance. The most supportive finding for this diagnosis is crackles in both lung bases.
Rationale 4: There are no data that support Impaired Gas Exchange as a diagnosis.

[Lisaclaire]

Gracias!

[debra928]

Excellent