The nurse is preparing to set up the oxygen administration and apply the simple face mask. What should the nurse do before applying the face mask? Select all that apply.
Determine if the client needs to go to the bathroom.
Identify the client using 2 client identifiers.
Perform hand hygiene.
Brush the client's teeth.
Don gloves.
Check the skin around the face.
Assess respiratory function.
Correct Answer : B,C,E,F,G
The correct answer is choice b. Identify the client using 2 client identifiers, c. Perform hand hygiene, e. Don gloves, f. Check the skin around the face, and g. Assess respiratory function.
Choice A rationale:
Determining if the client needs to go to the bathroom is not directly related to the immediate preparation for oxygen administration. However, it can be considered as part of overall patient comfort and care.
Choice B rationale:
Identifying the client using 2 client identifiers is crucial to ensure the correct patient is receiving the correct treatment, which is a standard safety protocol in healthcare settings.
Choice C rationale:
Performing hand hygiene is essential to prevent the spread of infection and maintain a sterile environment.
Choice D rationale:
Brushing the client’s teeth is not a necessary step before applying a simple face mask for oxygen administration. It is more related to general oral hygiene.
Choice E rationale:
Donning gloves is important to protect both the nurse and the patient from potential contamination and infection.
Choice F rationale:
Checking the skin around the face is important to ensure there are no existing sores or irritations that could be exacerbated by the mask.
Choice G rationale:
Assessing respiratory function is critical to determine the patient’s baseline respiratory status and to monitor the effectiveness of the oxygen therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
A regular rapid heartbeat (tachycardia) is a common side effect of albuterol, a bronchodilator that relaxes the muscles in the airways to improve breathing. It's often expected after repeated doses. While it warrants monitoring, it doesn't necessarily require immediate intervention unless it becomes significantly elevated or causes other symptoms.
Choice B rationale:
Increased anxiety can also accompany breathing difficulties and albuterol administration. It's crucial to address anxiety, but it's not the most urgent finding in this scenario. Calming techniques and reassurance can often help manage anxiety, while more severe cases might require additional interventions.
Choice C rationale:
Uncontrollable shaking (tremors) is a more serious side effect of albuterol, indicating excessive stimulation of the sympathetic nervous system. It can progress to serious complications like seizures or cardiac events. Immediate intervention is crucial to prevent these risks. Actions might include:
Holding the next albuterol dose Notifying the healthcare provider Monitoring vital signs closely
Administering medications to counteract the tremors, such as beta-blockers, if ordered
Choice D rationale:
Throat irritation is a possible side effect of albuterol, but it's generally mild and self-limiting. It doesn't typically warrant immediate intervention in the absence of other concerning symptoms.
Correct Answer is C
Explanation
Rationale for Choice A:
Serum Helicobacter pylori (H. pylori) antibody results are not directly relevant to the diagnosis or management of acute pancreatitis. While H. pylori infection can cause gastritis and peptic ulcers, it is not a common cause of pancreatitis.
Urine output amounts are important to monitor in patients with pancreatitis to assess for dehydration and kidney function. However, they are not as specific to the diagnosis of pancreatitis as other findings.
Rationale for Choice B:
Reports of chronic constipation are not typically associated with acute pancreatitis.
Serum gastrin levels are used to diagnose conditions such as Zollinger-Ellison syndrome, which is characterized by excessive acid production in the stomach. They are not relevant to the diagnosis of pancreatitis.
Rationale for Choice C:
Severity of nausea and vomiting are key symptoms of pancreatitis. The severity of these symptoms can help to gauge the severity of the pancreatitis and guide treatment decisions.
Serum amylase results are a highly sensitive and specific marker for pancreatitis. Elevated levels of amylase in the blood strongly suggest the presence of pancreatitis.
Rationale for Choice D:
Presence of bowel sounds can be variable in patients with pancreatitis and are not always reliable indicators of the severity of the condition.
Degree of abdominal pain is a subjective symptom that can be difficult to assess accurately. While it is an important symptom of pancreatitis, it is not as objective as other findings such as serum amylase levels.
Therefore, the most valuable information to report to the healthcare provider in this case is the severity of nausea and vomiting and serum amylase results.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.