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Patient Data

Exhibits

What should the nurse do before applying the face mask? Select that apply.

Perform hand hygiene

Identify the client using Z client identifiers

Determine if the client needs to go to the bathroom

Check the skin around the face

Don gloves

Brush the client's teeth

Assess respiratory function

Answer and Explanation

Correct Answer : A,B,D,E,G

A. Hand hygiene is essential to prevent the transmission of microorganisms and maintain infection control standards.
B. Verifying the client's identity using two unique identifiers, such as name and date of birth, helps prevent errors and ensures that the intervention is performed on the correct individual.
D. Assessing the skin around the face helps identify any abnormalities, irritation, or contraindications to applying the face mask, such as open wounds or dermatitis.
E. Wearing gloves helps prevent the transmission of microorganisms and protects both the nurse and the client during the application of the face mask.
G. Assessing respiratory function helps determine the client's need for the face mask and ensures that it is applied appropriately based on the client's respiratory status and needs.
C. While it's important to address the client's toileting needs, determining whether the client needs to go to the bathroom is not directly related to the application of a face mask unless there are specific concerns about the client's comfort or ability to tolerate the mask.
F. Brushing the client's teeth is not typically performed before applying a face mask unless there are specific clinical indications or the client requests oral care. However, oral care may be performed as part of routine hygiene practices or if the client is intubated and oral hygiene is necessary.

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Correct Answer is B

Explanation

B. When purulent drainage is observed at a wound site, obtaining a culture of the drainage is essential for identifying the specific microorganisms causing the infection and determining their sensitivity to antibiotics.

A. Serum blood glucose level is not directly relevant to the assessment of purulent drainage at a wound site.

C. An elevated CRP level may indicate the presence of infection but obtaining a CRP level may not be as immediate or specific as obtaining a wound culture.

D. Blood pH level is not directly relevant to the assessment of purulent drainage at a wound site.

A. Imbalanced nutrition: less than body requirements. B. Risk for aspiration related to difficulty swallowing. C. Chronic pain related to tissue destruction by tumor. D. Anxiety and grieving related to progression of disease.

Correct Answer is B

Explanation

B. Aspiration can lead to serious respiratory complications such as pneumonia. Since the client reports difficulty swallowing (dysphagia) and has a high pain level, addressing the risk for aspiration is crucial to prevent further complications.

A. While nutrition is essential for overall health, it may not be the priority in this case given the severity of other symptoms such as pain, dysphagia, and anxiety.

C. Esophageal cancer can cause significant pain due to tissue destruction by the tumor, which can affect the client's quality of life and ability to function. This however, should be addressed after immediate concerns in the ABCs.

D. While addressing the client's emotional needs is important for holistic care, it may not be the immediate priority compared to managing symptoms such as pain and dysphagia,

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Patient Data Exhibits What should the nurse do before applying the face mask? Select that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

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?

Correct Answer is B

Explanation

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Patient Data Exhibits What order(s) would the nurse question? (Select all that apply.)

Patient Data

Exhibits

What should the nurse do before applying the face mask? Select that apply.