A nurse is assisting with the care of a 2-year-old child.

Select the 6 findings that require immediate follow-up.

A. Air is heard escaping from around the mask: Escaping air indicates a poor seal, which compromises the delivery of high-concentration oxygen. A properly functioning non-rebreather mask should have a snug fit to the face, minimizing leaks and ensuring the client receives the intended oxygen concentration.

B. The flow control meter dial is at the correct setting: While setting the prescribed flow rate is necessary, the flow meter alone does not confirm that the mask or reservoir is functioning properly. The actual delivery of oxygen to the client depends on correct assembly, reservoir inflation, and mask seal.

C. The attached reservoir bag is inflated: An inflated reservoir bag indicates that oxygen is flowing into the bag and that the client will receive near 100% oxygen during inspiration. Proper inflation confirms that the one-way valves are functioning and that the mask is delivering high-concentration oxygen as intended.

D. The exhalation ports are covered during inspiration and expiration: Exhalation ports on a non-rebreather mask should remain open to allow carbon dioxide to escape while one-way valves prevent room air from entering during inspiration. Covered ports would restrict gas exchange and compromise oxygen delivery, indicating malfunction.

A. Ask the client whether they have advance directives: Upon admission, the nurse is responsible for determining whether the client has completed any advance directives, such as a living will or durable power of attorney for health care. Directly asking the client ensures accurate, up-to-date information and respects client autonomy.

B. Refer to the client's identification card for their advance directives status: An identification card may indicate the existence of an advance directive, but it does not confirm current validity or specific wishes. Relying solely on an ID card does not ensure that documentation is available or accurately reflects the client’s present decisions.

C. Verify the client's advance directives with their health care surrogate: Contacting the health care surrogate is not the first step if the client is competent and able to communicate. The client remains the primary decision-maker unless deemed incapacitated. Verification with a surrogate is appropriate only when the client cannot provide information.

D. Check for a written do-not-resuscitate prescription in the client's medical record: A do-not-resuscitate (DNR) order is only one type of directive and may not reflect the presence of a broader advance directive. Additionally, a DNR must be written as a provider order and may not exist at admission even if the client has other advance directives in place.