A nurse is caring for an adult with a partial rebreather mask. The oxygen reservoir bag does not deflate completely during inspiration, and the respiratory rate is 14 breaths per minute. What action should the nurse implement?

A nurse is caring for an adult with a partial rebreather mask. The oxygen reservoir bag does not deflate completely during inspiration, and the respiratory rate is 14 breaths per minute. What action should the nurse implement?

• A. Encourage the client to take deep breaths.
• B. Increase the liter flow of oxygen.
• C. Remove the mask to deflate the bag.
• D. Document the assessment data.

Answer: (D)

Understanding how to interpret the behavior of an oxygen delivery device and the patient’s breathing is key here. With a partial rebreather mask, the reservoir bag serves as a supply of high-concentration oxygen that the patient can draw from during inspiration. The bag should deflate as the patient inhales, indicating oxygen from the reservoir is contributing to the breath, but it should not necessarily collapse completely every time. If the patient isn’t showing signs of distress and the respiratory rate is within a normal range, this observation alone doesn’t mandate an intervention. In this scenario, the respiratory rate is 14 breaths per minute, which is within a typical resting range for an adult, and there’s no mention of hypoxia, agitation, or increased work of breathing. Therefore, the best action is to document this assessment data and continue monitoring. This keeps you accurately tracking the patient’s status and ready to respond if the situation changes—for example, if the bag’s behavior shifts (deflating completely or not deflating at all) or if the patient develops signs of inadequate oxygenation or CO2 retention, at which point you would reassess the flow rate or device.

Understanding how to interpret the behavior of an oxygen delivery device and the patient’s breathing is key here. With a partial rebreather mask, the reservoir bag serves as a supply of high-concentration oxygen that the patient can draw from during inspiration. The bag should deflate as the patient inhales, indicating oxygen from the reservoir is contributing to the breath, but it should not necessarily collapse completely every time. If the patient isn’t showing signs of distress and the respiratory rate is within a normal range, this observation alone doesn’t mandate an intervention.

In this scenario, the respiratory rate is 14 breaths per minute, which is within a typical resting range for an adult, and there’s no mention of hypoxia, agitation, or increased work of breathing. Therefore, the best action is to document this assessment data and continue monitoring. This keeps you accurately tracking the patient’s status and ready to respond if the situation changes—for example, if the bag’s behavior shifts (deflating completely or not deflating at all) or if the patient develops signs of inadequate oxygenation or CO2 retention, at which point you would reassess the flow rate or device.