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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Checking the patient's temperature again is not a priority at this time. The patient's temperature is within the normal range, and there is no indication that it is the cause of the patient's hypoxia.
Focusing on temperature measurement could delay more crucial interventions to address the patient's breathing difficulty.
Choice B rationale:
While monitoring the patient's heart rate is important, it is not the most immediate priority in this situation. The patient's heart rate is elevated, but it is not dangerously high.
The elevated heart rate is likely a compensatory response to the patient's low oxygen saturation. Addressing the underlying cause of the hypoxia, which is likely respiratory in nature, will also help to stabilize the heart rate.
Choice C rationale:
Observing the patient's breathing is the most important action the nurse can take at this time. The patient's respirations are rapid and shallow, indicating respiratory distress.
This is a serious condition that requires immediate intervention. By observing the patient's breathing, the nurse can assess the severity of the distress and determine the best course of action.
The nurse can observe for signs of increased work of breathing, such as use of accessory muscles, nasal flaring, and retractions. They can also auscultate the lungs to assess for any abnormal breath sounds, such as wheezing or crackles.
This information will help the nurse to determine the underlying cause of the respiratory distress and to initiate appropriate interventions, such as administering oxygen, positioning the patient, or calling for assistance from a respiratory therapist.
Choice D rationale:
Checking the patient's blood pressure is not a priority at this time. The patient's blood pressure is within the normal range. While it is important to monitor the patient's blood pressure, it is not the most immediate concern in this situation.
Correct Answer is A
Explanation
Choice A rationale:
Hemoglobin A1C (HbA1C) is a blood test that reflects a person's average blood glucose levels over the past 2-3 months. It's considered the gold standard for diagnosing and monitoring diabetes.
An HbA1C level of 8.29% is significantly elevated above the reference range of 4-5.99%, indicating a high probability of diabetes.
The patient's HbA1C has also increased from 7.59% three months ago, suggesting a worsening of glycemic control.
Diabetes mellitus is a chronic metabolic disorder characterized by elevated blood glucose levels due to impaired insulin production or action, or both.
Common symptoms of diabetes include increased thirst, frequent urination, fatigue, blurred vision, and slow-healing wounds.
Early diagnosis and treatment of diabetes are crucial to prevent complications such as heart disease, stroke, kidney disease, nerve damage, and vision loss.
Choice B rationale:
Hypoglycemia refers to abnormally low blood glucose levels, typically below 70 mg/dL. It's often caused by excessive insulin or medication, missed meals, or strenuous exercise.
The patient's HbA1C level of 8.29% does not support a diagnosis of hypoglycemia.
Choice C rationale:
Hyperglycemia refers to abnormally high blood glucose levels, typically above 180 mg/dL. It can be caused by diabetes, stress, infection, or certain medications.
While the patient's HbA1C level does indicate hyperglycemia, it's specifically the pattern of elevated HbA1C over time that points to a diagnosis of diabetes mellitus, rather than transient hyperglycemia.
Choice D rationale:
Prediabetes is a condition where blood glucose levels are higher than normal, but not high enough to be classified as diabetes. People with prediabetes are at increased risk of developing diabetes.
The patient's HbA1C level of 8.29% is above the threshold for prediabetes, which is typically 5.7-6.4%.
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