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 B

Explanation

Choice A reason: Printing electronic medical record (EMR) from backup server is not the best action to take first. It may not be possible or feasible to access the backup server if the system is down. It may also delay the communication and delivery of the prescriptions to the lab.

Choice B reason: Notifying information services department of the situation is the best action to take first. It alerts the experts who can troubleshoot and fix the problem as soon as possible. It also allows the nurse to obtain guidance on how to proceed with the documentation and prescriptions.

Choice C reason: Identifying information as late entry in the record is a relevant action to take, but not the first one. It ensures the accuracy and completeness of the EMR, but it does not address the immediate issue of the system failure. The nurse may not be able to enter the information until the system is restored.

Choice D reason: Waiting for notification that the system has been rebooted is not a proactive action to take first. It may waste valuable time and compromise the client's care. The nurse should not assume that the system will be rebooted automatically or quickly.

A. Abdominal girth. B. Breath sounds. C. Bowel sounds. D. Vital signs.

Correct Answer is D

Explanation

Choice A reason: This is not the most important assessment because abdominal girth is not a reliable indicator of fecal impaction. Abdominal girth can vary depending on the client's body type, fluid status, and other factors.

Choice B reason: This is also not the most important assessment because breath sounds are not directly related to fecal impaction. Breath sounds can be affected by respiratory conditions, smoking, allergies, and other factors.

Choice C reason: This is another incorrect choice because bowel sounds are not the most important assessment either. Bowel sounds can be diminished or absent in clients with fecal impaction, but they can also be altered by other gastrointestinal disorders, medications, and dietary factors.

Choice D reason: This is the correct choice because vital signs are the most important assessment prior to initiating digital removal of a fecal impaction. Vital signs can indicate the client's hemodynamic status, pain level, and risk of complications such as vagal stimulation, perforation, or infection. The nurse should monitor the client's blood pressure, pulse, respirations, and temperature before, during, and after the procedure.

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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

The nurse is entering prescriptions for lab work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?

Correct Answer is B

Explanation

Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

Correct Answer is D

Explanation

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