A nurse is caring for a client who is using a non-rebreather mask for oxygen delivery. The nurse should identify which of the following as an indication that the equipment is functioning properly?

Air is heard escaping from around the mask.

The flow control meter dial is at the correct setting.

The attached reservoir bag is inflated.

The exhalation ports are covered during inspiration and expiration.

Answer and Explanation

The Correct Answer is C

A. Air escaping from around the mask indicates a poor mask seal, which would lead to inadequate oxygen delivery and is not an indication of proper equipment function.
B. The flow control meter dial being at the correct setting ensures the appropriate flow rate of oxygen but does not directly indicate the functionality of the mask and reservoir system. C. The attached reservoir bag should be inflated with oxygen when the mask is properly connected and functioning, indicating the delivery of high-concentration oxygen to the client.
D. The non-rebreather mask should not have exhalation ports that are covered during inspiration and expiration; rather, it should allow exhaled air to escape to prevent carbon dioxide buildup within the mask.

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Correct Answer is C

Explanation

A. Lip-smacking may indicate hunger or a desire to feed but is not necessarily indicative of pain in a newborn with shoulder dystocia.
B. Stiff posture may indicate discomfort or distress, but it is not specific to pain and can be caused by various factors.
C. A weak cry can be a sign of pain or distress in newborns. It may indicate that the newborn is experiencing discomfort related to the shoulder dystocia.
D. Tongue-darting is a normal reflex in newborns and is not typically associated with pain.

A. The client's foot feels cooler than in the previous assessment. B. The client's pedal pulse in the right foot is not palpable. C. The client's capillary refill time is 5 seconds in the toes. D. The client reports a pain level of 8 on a scale from 3 to 10.

Correct Answer is B

Explanation

A. The client's foot feels cooler than in the previous assessment: While decreased temperature can indicate decreased perfusion, the absence of a palpable pedal pulse is a more concerning finding.
B. The client's pedal pulse in the right foot is not palpable: This finding suggests compromised blood flow distal to the site of the bypass graft, which could indicate graft occlusion or impaired circulation.
C. The client's capillary refill time is 5 seconds in the toes: While prolonged capillary refill time can indicate impaired circulation, the absence of a palpable pedal pulse is a more concerning finding.
D. The client reports a pain level of 8 on a scale from 3 to 10: Pain is subjective and can be managed with analgesics, but the absence of a palpable pedal pulse indicates a more serious issue related to perfusion.

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A nurse is caring for a client who is using a non-rebreather mask for oxygen delivery. The nurse should identify which of the following as an indication that the equipment is functioning properly?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a newborn who has shoulder dystocia. The nurse should identify which of the following findings as an indication of pain?

Correct Answer is C

Explanation

A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?

Correct Answer is B

Explanation

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