When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

Assess the position of the mask on the client's face.

Release and reinsert the flowmeter in the wall outlet.

Attach the flowmeter to a humidification canister.

Adjust the flow rate to the prescribed liters per minute.

Answer and Explanation

The Correct Answer is B

Choice A reason: Assessing the position of the mask on the client's face is not the priority action. The mask may be well-fitted, but the oxygen delivery may be compromised by the faulty connection of the flowmeter.

Choice B reason: Releasing and reinserting the flowmeter in the wall outlet is the best action as it may correct the problem of the loose or misaligned connection. The nurse should ensure that the flowmeter is securely attached and that the oxygen is flowing properly.

Choice C reason: Attaching the flowmeter to a humidification canister is not necessary for oxygen delivery per mask. Humidification is usually added for high-flow oxygen devices such as nasal cannula or face tent.

Choice D reason: Adjusting the flow rate to the prescribed liters per minute is not the appropriate action. The flow rate may be correct, but the oxygen delivery may be impaired by the hissing sound indicating a leak or obstruction.

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Correct Answer is D

Explanation

Choice A reason: Continuing the blood pressure assessment until the last Korotkoff sound is heard is not the best action to implement next. It may result in an inaccurate measurement of the diastolic pressure, as the cuff pressure may be too low to detect the sound.

Choice B reason: Repositioning the stethoscope in the antecubital fossa over the palpable brachial pulse point is not a necessary action to implement next. It may not affect the accuracy of the blood pressure measurement, as the nurse already hears the Korotkoff sounds clearly.

Choice C reason: Inflating the cuff quickly to a higher mm Hg reading than the previously auscultated systolic sound is not a safe action to implement next. It may cause discomfort and injury to the client, as the cuff pressure may be too high and occlude the blood flow.

Choice D reason: Releasing the air and reinflating the cuff to 30 mm Hg above the client's previous systolic reading is the best action to implement next. It helps to avoid the auscultatory gap, which is a period of silence between the systolic and diastolic pressures. It also ensures that the cuff pressure is high enough to detect the true systolic and diastolic pressures.

A. Paper mask and gown. B. The nurse's stethoscope. C. Bed linens. D. Sputum specimen.

Correct Answer is A

Explanation

Choice A reason: Paper mask and gown are considered regulated medical waste, which means they are contaminated with blood, body fluids, or microorganisms that pose a potential risk of infection¹. Therefore, they should be placed in a designated biohazard bag before they are removed from the room and treated according to the facility's policies and procedures².

Choice B reason: The nurse's stethoscope is not a disposable item and does not need to be placed in a biohazard bag. However, it should be cleaned and disinfected after each use to prevent cross-contamination³.

Choice C reason: Bed linens are not classified as regulated medical waste unless they are soaked with blood or body fluids¹. They can be placed in a regular laundry bag and washed according to the facility's guidelines.

Choice D reason: Sputum specimen is a type of microbiology laboratory waste, which is regulated medical waste¹. However, it should not be placed in a biohazard bag, but in a leak-proof, puncture-resistant container that is labeled with a biohazard symbol. This ensures the safe transport and handling of the specimen.

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When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm Hg. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?

Correct Answer is D

Explanation

A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

Correct Answer is A

Explanation

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