A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via a simple face mask. Which of the following actions should the nurse take to ensure client safety?

Keep the side holes of the mask closed.

Ensure the reservoir bag is inflated on expiration.

Apply petroleum jelly to the client's nostrils.

Attach a humidifier to the base of the flow meter.

Answer and Explanation

The Correct Answer is D

The correct answer is **d. Attach a humidifier to the base of the flow meter**.

Choice A rationale:

Keeping the side holes of the mask closed would restrict airflow and prevent the client from receiving the prescribed oxygen concentration. This action would be unsafe and should not be taken.

Choice B rationale:

Ensuring the reservoir bag is inflated on expiration is not necessary for a simple face mask. The reservoir bag is typically used with other oxygen delivery devices, such as a non-rebreather mask, to provide a higher concentration of oxygen. This action is not appropriate for the given scenario.

Choice C rationale:

Applying petroleum jelly to the client's nostrils is not a recommended action. Petroleum jelly can potentially cause irritation and dryness, which could lead to discomfort for the client. This action is not necessary for the safe administration of oxygen.

Choice D rationale:

Attaching a humidifier to the base of the flow meter is the appropriate action to ensure client safety. Humidifying the oxygen can help prevent drying of the client's airway and make the oxygen more comfortable to breathe. This is a recommended step when administering high-flow oxygen via a simple face mask.

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Correct Answer is A

Explanation

The correct answer is choice A: "Complained about having incisional pain."

Choice A rationale:

Documenting a client's complaints about pain, especially incisional pain, is crucial in an electronic health record. Pain assessment and management are essential aspects of client care, and including this information helps to track the client's pain level, the effectiveness of pain interventions, and any changes in their condition over time.

Choice B rationale:

While it's important to monitor fluid intake and output, stating that the client "Voided adequate amounts through the shift" might be relevant to the client's overall condition but lacks specific information. It doesn't address the reason for the assessment, and the focus should be on the client's immediate care needs and responses.

Choice C rationale:

Noting that the client "Became short of breath when ambulating" is significant for documenting any potential signs of respiratory distress during activity. This information provides valuable insights into the client's ability to tolerate physical exertion and might indicate a need for further assessment or interventions.

Choice D rationale:

Documenting that the client "Appeared to be sleeping while in bed" might not offer significant clinical information unless there is a specific reason for noting the client's sleep patterns. Sleep is an important aspect of recovery, but this choice lacks the context needed to make it a priority entry in the documentation.

A. Client reports voiding three times during the night. B. Client reports burning and discomfort with urination. C. The client's WBC count is 11,000/mm². D. The client's output was 60 mL for the past 3 hr.

Correct Answer is D

Explanation

The correct answer is choice d. The client’s output was 60 mL for the past 3 hr.

Choice A rationale:

Voiding three times during the night (nocturia) is common in chronic kidney disease (CKD) due to the kidneys’ inability to concentrate urine. While it should be monitored, it is not the most urgent issue.

Choice B rationale:

Burning and discomfort with urination could indicate a urinary tract infection (UTI), which is important to address but not as immediately critical as low urine output.

Choice C rationale:

A WBC count of 11,000/mm² is slightly elevated and could indicate an infection or inflammation, but it is not as urgent as the low urine output.

Choice D rationale:

Low urine output (oliguria) of 60 mL over 3 hours is a critical finding in CKD patients. It indicates potential acute kidney injury or worsening kidney function, which requires immediate attention to prevent further complications.

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A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via a simple face mask. Which of the following actions should the nurse take to ensure client safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting client care in a client's electronic health record. Which of the following entries should the nurse include in the documentation?

Correct Answer is A

Explanation

A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority to report to the provider?

Correct Answer is D

Explanation

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