A nurse is providing reinforcing discharge instructions to a client who has a prescription for oxygen use at home.
Which of the following information should the nurse include? (Select all that apply.)
Family members who smoke must be at least 10 ft from the client when oxygen is in use.
Nail polish remover or hair spray should not be used near a client who is receiving oxygen.
A "No Smoking" sign should be placed on the front door.
Cotton bedding and clothing should be replaced with items made from wool.
A fire extinguisher should be readily available in the home.
Correct Answer : D
Choice A rationale:
Tying the straps of the restraints in a double knot is incorrect. This action can make it difficult to quickly release the restraints in case of an emergency. A single, quick-release knot is recommended to ensure the client's safety.
Choice B rationale:
Tying the restraints to the side rails is incorrect. Attaching restraints to the side rails can cause injury to the client and is not a proper restraint application method. Restraints should be tied to the bed frame, not the side rails, to prevent harm.
Choice C rationale:
Placing the padding of the restraints against the client's bony prominences is incorrect. While padding is important to prevent skin breakdown and pressure ulcers, the correct placement of the padding alone does not indicate a comprehensive understanding of proper restraint application.
Choice D rationale:
Inserting one finger between the client's wrist and the restraint is the correct action. This technique ensures that the restraints are not too tight, allowing for proper circulation and preventing injury to the client. The ability to insert one finger indicates that the restraints are snug but not constrictive, maintaining the client's safety and comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["473"]
Explanation
The correct answer is choice: 473.
To convert 4 ounces to milliliters (mL), the following steps can be taken:
Understand the Conversion Factor: 1 fluid ounce (oz) is approximately 29.57 mL. Therefore, 4 oz can be converted to mL using the following calculation: 4 × 29.57 = 118.28
4oz × 29.57mL/oz = 118.28mL.
Convert Cups to Ounces: 1 cup is equal to 8 fluid ounces.
Therefore, 1 cup is 8 × 29.57= 236.56
8oz × 29.57mL/oz = 236.56mL.
So, 1 cup is equal to 236.56 mL. The correct answer is 473 mL (2 cups)
Correct Answer is ["A"]
Explanation
Choice A rationale:
Maintaining the patency of the client's airway is the priority action. During a seizure, the client may lose consciousness and have difficulty breathing. Ensuring a clear airway is essential to prevent hypoxia and maintain oxygenation. This can be achieved by positioning the client on her side and removing any obstructions from her mouth to allow for adequate airflow.
Choice B rationale:
Identifying the poison the client ingested is important for providing appropriate medical treatment, but it is not the priority action in this scenario. Airway management takes precedence because it addresses the immediate threat to the client's life.
Choice C rationale:
Measuring the client's blood pressure is a necessary assessment, but it is not the priority during an active seizure. Airway management and seizure control are the immediate concerns. Once the seizure is controlled and the airway is secured, other assessments, including blood pressure measurement, can be performed.
Choice D rationale:
Positioning the client on her side is a correct action, but it should be done after ensuring the patency of the airway. Placing the client on her side helps prevent aspiration in case of vomiting during or after the seizure. However, it is not the priority over ensuring the client can breathe properly.
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