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Exhibits

The nurse is preparing to set up the oxygen administration and apply the simple face mask. Which should the nurse do before applying the face mask? Select that apply.

Perform hand hygiene

Brush the client's teeth

Check the skin around the face

Identify the client using 2 client identifiers

Assess respiratory function

Don gloves

Determine if the client needs to go to the bathroom

Answer and Explanation

Correct Answer : A,C,D,E

A. Performing hand hygiene is crucial to prevent the spread of infection before any patient interaction or procedure.
B. Brushing the client’s teeth is not necessary before applying an oxygen mask and does not pertain to immediate care.
C. Checking the skin around the face is important to ensure there are no irritations or breakdowns that could affect the mask's fit and the patient's comfort.
D. Identifying the client using 2 identifiers is a critical safety step to ensure the correct patient receives the intended care.
E. Assessing respiratory function is important to determine the severity of the client’s condition and the appropriate oxygen delivery method.
F. Donning gloves is not required for applying a simple face mask unless there is potential for contact with blood or bodily fluids.
G. Determining if the client needs to go to the bathroom is not directly related to applying the face mask and should be assessed but is not critical before mask application.

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Correct Answer is A

Explanation

A. The symptoms of persistent upper abdominal pain radiating to the back, elevated serum amylase and lipase levels, vomiting, and fever suggest acute pancreatitis, which can occur after cholecystectomy due to potential injury to the pancreas or bile duct obstruction.
B. While biliary duct obstruction can occur postoperatively, the significantly elevated amylase and lipase levels, along with the described symptoms, more strongly indicate pancreatitis.
C. Surgical site infection typically presents with localized symptoms rather than systemic symptoms like elevated amylase and lipase.
D. Hepatorenal failure is unlikely to present with these specific gastrointestinal symptoms and enzyme elevations.

A. Observe body language and movement. B. Identify effective pain relief measures. C. Ask the client to describe the pain. D. Provide a numeric pain scale.

Correct Answer is C

Explanation

A. Observing body language and movement can provide clues about the client's pain but does not directly assess the quality of the pain experienced.
B. Identifying effective pain relief measures is important for managing pain but does not assess the quality of pain itself.
C. Asking the client to describe the pain directly assesses its quality, allowing the nurse to understand its characteristics, such as intensity, duration, and type (e.g., sharp, dull, throbbing).
D. Providing a numeric pain scale is useful for quantifying pain intensity but does not capture the qualitative aspects of the pain experience.

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Exhibits The nurse is preparing to set up the oxygen administration and apply the simple face mask. Which should the nurse do before applying the face mask? Select that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

To assess the quality of an adult client's pain, which approach should the nurse use?

Correct Answer is C

Explanation

The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?

A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

The healthcare provider prescribes bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole for a client with a Helicobacter pylori (H. pylori) infection. Prior to administering the H. pylori treatment regimen, the nurse should review the electronic medical record for which medication?

An adult client is admitted with AIDS and oral Candida albicans manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide to the UAP?

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

Exhibits

The nurse is preparing to set up the oxygen administration and apply the simple face mask. Which should the nurse do before applying the face mask? Select that apply.