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Exhibits

Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

Positioning the client with the head of the bed elevated

Avoid treating fever with antipyretics

Encourage the client to take breaks from the oxygen mask every few hours

Providing suctioning so the client does not have to cough

Assist the client in ambulating safely

Asking the client to do quick, shallow breaths

Teaching the client to cough at least once an hour

Answer and Explanation

Correct Answer : A,E,G

A. Positioning the client with the head of the bed elevated helps improve lung expansion and facilitates better ventilation and oxygenation, reducing the work of breathing.
B. Avoid treating fever with antipyretics is not appropriate, as managing fever can help reduce metabolic demand and improve overall comfort, which aids in ventilation.
C. Encouraging the client to take breaks from the oxygen mask is not advisable, as consistent oxygen delivery is critical for maintaining adequate oxygen saturation, especially in cases of pneumonia.
D. Providing suctioning so the client does not have to cough may not be necessary; coughing is a natural mechanism to clear secretions and improve airway patency.
E. Assisting the client in ambulating safely promotes lung expansion, enhances circulation, and aids in the mobilization of secretions, contributing positively to ventilation and oxygenation.
F. Asking the client to do quick, shallow breaths is counterproductive, as it can lead to inadequate ventilation and decreased oxygenation; deep breathing is preferred.
G. Teaching the client to cough at least once an hour is essential for clearing secretions and improving lung function, thereby enhancing ventilation and oxygenation.

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Correct Answer is D

Explanation

A. Use salt tablets after strenuous exercise is incorrect. Clients with hypernatremia should avoid excessive sodium intake, including salt tablets, as this can worsen the condition.

B. Drink plenty of water whenever thirsty is incorrect. Thirst is a late sign of dehydration, and clients with hypernatremia should be encouraged to drink water regularly, even before feeling thirsty, to maintain proper hydration and correct sodium imbalances.

C. Monitor daily urine output volume is incorrect. While monitoring fluid balance is important, urine output alone does not directly address sodium intake or management, making reviewing food labels for sodium content a more critical intervention.

D. Review food labels for sodium content is correct. Clients with hypernatremia should limit sodium intake by carefully reading food labels and avoiding processed, canned, and fast foods that are high in sodium.

A. Perform hand hygiene B. Brush the client's teeth C. Check the skin around the face D. Identify the client using 2 client identifiers E. Assess respiratory function F. Don gloves G. Determine if the client needs to go to the bathroom

Correct Answer is ["A","C","D","E"]

Explanation

A. Performing hand hygiene is crucial to prevent the spread of infection before any patient interaction or procedure.
B. Brushing the client’s teeth is not necessary before applying an oxygen mask and does not pertain to immediate care.
C. Checking the skin around the face is important to ensure there are no irritations or breakdowns that could affect the mask's fit and the patient's comfort.
D. Identifying the client using 2 identifiers is a critical safety step to ensure the correct patient receives the intended care.
E. Assessing respiratory function is important to determine the severity of the client’s condition and the appropriate oxygen delivery method.
F. Donning gloves is not required for applying a simple face mask unless there is potential for contact with blood or bodily fluids.
G. Determining if the client needs to go to the bathroom is not directly related to applying the face mask and should be assessed but is not critical before mask application.

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Exhibits Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

Correct Answer is D

Explanation

Exhibits The nurse is preparing to set up the oxygen administration and apply the simple face mask. Which should the nurse do before applying the face mask? Select that apply.

Correct Answer is ["A","C","D","E"]

Explanation

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Exhibits

Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.