A nurse is teaching a client about the proper use of a portable oxygen concentrator. Which statement by the client indicates a need for further teaching?

Correct Answer: C

Rationale: Rationale: The correct answer is C) "I can increase the oxygen flow rate if I feel short of breath." This statement indicates a need for further teaching because altering the oxygen flow rate without healthcare provider guidance can be dangerous. Adjusting the flow rate without proper assessment and instruction can lead to oxygen toxicity or inadequate oxygen delivery, both of which can be harmful to the client's health. Option A) "I can use the device during air travel" is a correct statement as portable oxygen concentrators are allowed on airplanes with prior approval. Option B) "I should avoid using the device near open flames" is also correct as oxygen supports combustion, and using oxygen near open flames can lead to a fire hazard. Option D) "I need to check the battery life before leaving home" is a valid statement as ensuring the device has sufficient battery life is essential for uninterrupted oxygen therapy. In an educational context, it is crucial to emphasize the importance of following healthcare provider instructions regarding oxygen therapy, including not adjusting the flow rate without proper guidance. Educating clients on the safe use of portable oxygen concentrators helps ensure their well-being and prevent potential complications.

Correct Answer: A

Rationale: In the context of carbon monoxide poisoning, the priority action for the nurse is to administer 100% oxygen via a non-rebreather mask (Option A). This is because carbon monoxide has a much higher affinity for hemoglobin than oxygen, leading to tissue hypoxia. By providing high-flow oxygen, the nurse can effectively displace carbon monoxide from hemoglobin and increase the oxygen-carrying capacity of the blood, thereby improving tissue oxygenation. Option B, obtaining a carboxyhemoglobin level, is important for confirming the diagnosis of carbon monoxide poisoning but is not the priority action in an acute situation where immediate intervention is required to improve oxygenation. Option C, placing the client in a hyperbaric oxygen chamber, is a treatment modality for severe cases of carbon monoxide poisoning but may not be readily available or feasible in all healthcare settings. Administering high-flow oxygen is the initial and more practical approach. Option D, initiating continuous pulse oximetry monitoring, is important for ongoing assessment but is not the priority over providing immediate oxygen therapy to address the hypoxia associated with carbon monoxide poisoning. In an educational context, understanding the pathophysiology of carbon monoxide poisoning and the rationale behind the treatment options is crucial for nurses to prioritize interventions effectively in emergency situations. Administering oxygen promptly can be life-saving in cases of carbon monoxide poisoning, making it the priority action for nurses caring for these patients.

Correct Answer: D

Rationale: In this NCLEX-style question on oxygenation, the correct answer is D) 85%. This level indicates significant hypoxemia, which requires immediate nursing intervention to prevent potential harm to the client. Oxygen saturation below 90% is considered a critical level where prompt action is necessary to ensure adequate oxygenation to vital organs. Option A) 94% is within the normal range for oxygen saturation and does not require immediate intervention. Option B) 92% is slightly lower but still generally acceptable in most cases, especially if the client does not have underlying respiratory conditions. Option C) 90% is a borderline level where intervention may be needed depending on the client's condition, but it is not as critical as 85%. Educationally, understanding oxygen saturation levels is crucial for nurses to assess and manage a client's respiratory status effectively. Recognizing when oxygen saturation falls below a certain threshold is essential for early intervention and preventing complications related to hypoxemia. Nurses must be vigilant in monitoring oxygen saturation levels and respond promptly to deviations from the normal range to ensure optimal patient outcomes.

Correct Answer: D

Rationale: In this scenario, the most concerning finding for a client with COPD experiencing an exacerbation is the use of accessory muscles for breathing (Option D). This indicates severe respiratory distress and impending respiratory failure. Option A, a productive cough with yellow sputum, is a common symptom in COPD exacerbations but does not indicate immediate respiratory compromise. Option B, a respiratory rate of 24 breaths per minute, while elevated, may be seen in COPD exacerbations but is not as critical as the use of accessory muscles. Option C, an oxygen saturation of 88%, is low but may be expected in COPD; however, the use of accessory muscles indicates severe respiratory distress. Educationally, understanding these findings is crucial for nurses to prioritize interventions and escalate care appropriately for clients with COPD exacerbations. Recognizing the significance of accessory muscle use can prompt prompt intervention and prevent respiratory failure, highlighting the importance of ongoing assessment and monitoring in respiratory conditions.

Correct Answer: C

Rationale: In this scenario, option C, "Tracheal deviation to the unaffected side," requires immediate intervention. Tracheal deviation is a critical sign that can indicate tension pneumothorax, a life-threatening emergency where air accumulates in the pleural space under pressure, pushing the mediastinum and trachea to the unaffected side. This compromises cardiac output and can lead to respiratory failure and cardiac arrest. Option A, "Oxygen saturation of 95%," is within the expected range and does not indicate an immediate concern. Option B, "Respiratory rate of 16 breaths per minute," is also within the normal range for an adult and does not signal an urgent issue. Option D, "Mild discomfort at the procedure site," is common after thoracentesis and can be managed with pain relief measures. It does not require immediate intervention unless it worsens or is accompanied by other concerning symptoms. Educationally, it is crucial for nurses to recognize and respond promptly to signs of respiratory distress post-thoracentesis to prevent complications. Understanding the significance of tracheal deviation and differentiating it from expected post-procedure discomfort is vital in providing safe and effective care to patients undergoing thoracentesis.