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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Condition: The combination of severe abdominal pain, elevated inflammatory markers, and risk factors, along with the need for urgent care and surgical evaluation, suggests that GERD may be a significant underlying issue, especially in the context of potential complications.
Actions to Take
- Prepare for surgery: Given the client's presentation of severe abdominal pain, elevated white blood cell count, and possible abdominal rigidity, surgical intervention may be necessary to rule out conditions like acute cholecystitis or perforation.
- Transfer to high-risk level of care: Due to the client's elevated vital signs, including tachycardia and fever, along with the severe pain radiating to the shoulder, close monitoring in a high-risk area is warranted.
Parameters to Monitor
- Pain: Regular assessment of the client's pain level is crucial to evaluate the effectiveness of interventions and to monitor any changes in the severity of the pain.
- Signs and symptoms of abdominal perforation: Monitoring for indications such as increased abdominal tenderness, rigidity, fever, and changes in vital signs is essential to detect any complications promptly.
Correct Answer is C
Explanation
A. A positive sputum smear and culture would indicate that the tuberculosis infection is still active, which is not an expected outcome of effective treatment with isoniazid.
B. Vertigo and tinnitus are not expected outcomes of isoniazid therapy; they may indicate side effects or adverse reactions, not effectiveness.
C. Decreased cough and sputum would demonstrate the effectiveness of isoniazid in treating active tuberculosis, as the medication should lead to symptomatic improvement and reduced bacterial load.
D. Decreased appetite and weight loss can be associated with tuberculosis but are not direct indicators of medication effectiveness.
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