When administering oxygen with a partial rebreather mask, which of the following observations is most important to report to the respiratory therapy departments?

Correct Answer: B

Rationale: The correct answer is B: The reservoir bag collapses during inspiration. This is important to report because it indicates inadequate oxygen delivery to the patient, potentially leading to hypoxemia. The reservoir bag should remain inflated to ensure a sufficient oxygen supply. A: Moisture accumulation inside the mask is common and not a cause for concern unless excessive. C: The mask covering the mouth and nose is expected and does not impact oxygen delivery. D: The strap being snug ensures a proper fit but does not directly impact oxygen delivery. In summary, choice B is the correct answer as it directly relates to the effectiveness of oxygen delivery, while the other choices are not as critical in this context.

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. Heparin is administered subcutaneously, not intramuscularly, so aspirating is not necessary. 2. Aspirating can cause bruising or bleeding due to the fragility of subcutaneous blood vessels. 3. Massaging after the injection can lead to hematoma formation. 4. By not aspirating before or massaging after the injection, the risk of complications is minimized. Summary: A: Incorrect - Aspirating can lead to complications, and massaging may cause hematoma. B: Incorrect - Massaging for one minute is excessive and can increase the risk of hematoma formation. D: Incorrect - Massaging the site can lead to bruising, and aspiration is unnecessary and potentially harmful.

Correct Answer: C

Rationale: The correct answer is C because raising the fluid container 12-18 inches above the patient's anus ensures a slow, controlled flow of the enema solution into the rectum, allowing for proper cleansing without causing discomfort or injury. This height creates enough pressure to facilitate the flow but prevents excessive pressure that could lead to bowel perforation. Choice A is incorrect because cold water can cause discomfort and cramping, while warm water is recommended for its soothing effect. Choice B is incorrect as the rectal tube should be inserted 3-4 inches into the rectum to ensure proper administration. Choice D is incorrect as removing and reinserting the rectal tube multiple times can disrupt the flow and increase the risk of introducing air into the rectum.

Correct Answer: A

Rationale: Correct Answer: A - Measure the legs before applying stockings to assure proper fit. Rationale: Proper fit is crucial for the effectiveness of anti-embolic stockings. Measuring the legs ensures a snug but not too tight fit, promoting circulation without causing discomfort or complications. This step helps prevent skin breakdown, nerve compression, and circulation issues. Summary of Incorrect Choices: B: Applying the stockings while the client is sitting in a chair - This is incorrect as stockings should be applied when the client is lying down with legs elevated to reduce swelling and make application easier. C: Massage the legs when removing the stockings - Massaging the legs can dislodge blood clots, which is dangerous for clients wearing anti-embolic stockings. D: Leave the stockings in place for one week intervals - Stockings should be regularly removed and washed to maintain hygiene and prevent skin irritation or infections. Leaving them on for a week can lead to complications.

Correct Answer: B

Rationale: The correct answer is B: Increase your fluid intake to 2 to 3 L per day. This instruction is important after extracorporeal shock wave lithotripsy to help flush out the stone fragments and prevent urinary tract infections. Increasing fluid intake also helps prevent dehydration and promotes kidney function. A: Taking temperature every 4 hours is not necessary post-lithotripsy unless the client develops signs of infection. C: Applying an antibacterial dressing daily is not typically required after lithotripsy unless specifically instructed by the healthcare provider. D: Urine turning cherry red after lithotripsy is due to blood in the urine, which is expected, but this should resolve within 24-48 hours, not 5 to 7 days.