A collapsing or fully deflated non-rebreather reservoir bag means the client is not getting enough oxygen; correct immediately.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A client in shock is receiving supplemental oxygen. What is the primary rationale for oxygen therapy in shock?
Answer: A. Oxygen is administered in shock to maximize oxygen delivery to tissues that are already hypoperfused, helping to limit anaerobic metabolism and organ damage. It does not primarily treat anxiety, raise blood pressure directly, or warm the client.
Question 2 of 5
A client with COPD is receiving oxygen at 2 L/min via nasal cannula. Which finding would cause the nurse to be most concerned about oxygen-induced hypoventilation?
Answer: C. In some clients with chronic CO2 retention, high-flow oxygen can blunt the hypoxic drive and worsen hypoventilation, signaled by a rising PaCO2 with decreasing respirations and increasing drowsiness. Low-flow oxygen is targeted to keep SpO2 around 88 to 92 percent. The other findings are not signs of CO2 narcosis.
Question 3 of 5
A client in shock has a serum lactate level that is rising over several hours. The nurse interprets this trend as indicating:
Answer: A. An elevated and rising lactate reflects anaerobic metabolism from tissue hypoperfusion, a marker of inadequate oxygen delivery and worsening shock. A falling lactate suggests improving perfusion. Rising lactate is not a normal finding and signals the need for more aggressive resuscitation.
Question 4 of 5
A client with COPD requires oxygen. The nurse administers it at:
Answer: B. For chronic CO₂ retainers (COPD), give controlled LOW-flow oxygen (e.g., 1–2 L/min via nasal cannula) titrated to target saturation; very high flow can blunt the hypoxic drive. Always treat true hypoxia, but cautiously.
Question 5 of 5
A nurse is assisting with the delivery of a client experiencing shoulder dystocia. Which maneuver should the nurse perform first?
Answer: B. The McRoberts maneuver (hyperflexing the maternal thighs sharply against the abdomen) combined with suprapubic pressure is the first-line intervention for shoulder dystocia because it flattens the sacrum and rotates the symphysis to free the impacted shoulder. Fundal pressure is contraindicated as it worsens impaction.
Keep the streak going with more questions like these, each with a full rationale.
What is oxygen delivery devices?
Device choice matches the client's oxygen need while maintaining airway safety. Key principle: use the lowest effective FiO2, and oxygen supports combustion so keep it away from flames.
Key points to remember
- Nasal cannula delivers about 24 to 44% FiO2 at 1 to 6 L/min; humidify above 4 L/min to prevent drying.
- Simple mask delivers about 40 to 60% at 5 to 10 L/min; keep flow at 5 L/min or higher to flush CO2.
- Non-rebreather mask delivers the highest FiO2 (60 to 100%) for emergencies; keep the reservoir bag inflated and never let it collapse fully.
- Venturi mask delivers the most precise, fixed FiO2 (24 to 50%), making it ideal for COPD clients.
- In COPD clients who retain CO2, high oxygen can blunt the hypoxic drive; titrate carefully to target SpO2 (often 88 to 92%).
- Oxygen is a fire hazard: no smoking, open flames, or electric razors near it, and post 'oxygen in use' signs.
Nursing priorities
- Assess respiratory status, work of breathing, and SpO2 to guide device and flow selection.
- Apply the correct device and verify flow rate, mask fit, and an inflated reservoir bag (non-rebreather).
- Titrate to the prescribed SpO2 target and use the lowest effective concentration.
- Provide humidification and skin/mucous-membrane care (ears, nose, lips) to prevent breakdown.
- Enforce fire-safety precautions around the oxygen source.
Labs & values
Patient teaching
- Never smoke or allow open flames near oxygen and keep it away from heat sources.
- Do not change the flow rate yourself; report shortness of breath or skin irritation.
- Use water-based lubricant on dry lips/nose, not petroleum-based products, near oxygen.
Red flags: report now
- A collapsing or fully deflated non-rebreather reservoir bag means the client is not getting enough oxygen; correct immediately.
- Rising drowsiness, confusion, or worsening hypercapnia in a COPD client on high-flow oxygen requires reassessment and provider notification.
- Falling SpO2 despite oxygen, cyanosis, or increasing distress requires escalation of support and rapid response.
References
Clinical references for this topic
