A client is receiving oxygen via Venturi mask at 40%. On assessment the nurse finds the client cyanotic with labored respirations. Which action does the nurse perform first?
a. Remove bedding from around the adaptor opening.
b. Listen to lung sounds and obtain a respiratory rate.
c. Call respiratory therapy to check oxygen saturation.
d. Notify the provider or Rapid Response Team immediately.
A
The Venturi mask works by drawing in a specific amount of air to mix with the oxygen through holes in an adaptor fitted at the bottom of the mask. Holes of different sizes allow different amounts of room air to be entrained, changing the amount of oxygen delivered. Bedding (or clothing) wrapped around those holes would effectively change the FiO2 . The nurse should ensure that the holes remain unobstructed. Other options are appropriate but are not the first choice, because this simple step may be what solves the problem.
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1. Padding the bed around the head, foot, and side rails 2. Placing functional oral suction equipment in the room 3. Placing extremity restraints in the room for use if the client has a seizure 4. Keeping pillows handy to protect the client's head 5. Taping a bite block to the wall to protect the client from biting his or her tongue