Mark whether the statements by the new graduate nurse indicate understanding or no understanding of the use of the face mask in the care of this client.

I should clean the face mask once per shift

I should place the mask first over the nose and then cover the mouth

The client should take a 1 to 2 minute break from the face mask each hour

The mask should cover only the mouth and leave the nose open for expiration

I can adjust the oxygen level

Answer and Explanation

Correct Answer : B,C,E

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Correct Answer is A

Explanation

Choice A rationale
Testing the fluid on the dressing for glucose is the immediate action the nurse should take. Clear fluid could be cerebrospinal fluid (CSF), which is often released following spinal surgery. CSF contains glucose, so a positive glucose test would confirm it is CSF.
Choice B rationale
Replacing the dressing using a compression bandage is not the immediate action the nurse should take. While it is important to manage the drainage and prevent infection, the nurse first needs to identify what the clear fluid is.
Choice C rationale
Marking the drainage area with a pen and continuing to monitor is not the immediate action the nurse should take. While this can be part of ongoing wound care and monitoring, the nurse first needs to identify what the clear fluid is.

Choice D rationale
Documenting the findings in the electronic medical record is an important step, but it should not be the immediate action. The nurse first needs to identify what the clear fluid is, as it could indicate a complication from the surgery.

A. Cease the use of the nasal cannula. B. Reduce the flow rate to 1 L/minute. C. Apply lubricant to the cannula tubing. D. Attach padding around the cannula tubing.

Correct Answer is D

Explanation

Choice A rationale
Ceasing the use of the nasal cannula would interrupt the client’s oxygen therapy, which could potentially worsen their condition. Therefore, this is not the best course of action.
Choice B rationale
Reducing the flow rate to 1 L/minute may not be appropriate as the client’s oxygen needs may not be met at a lower flow rate. The redness under the chin is likely due to the friction from the cannula tubing, not the flow rate of the oxygen.
Choice C rationale
Applying lubricant to the cannula tubing may not be effective in preventing skin breakdown and could potentially cause additional discomfort or complications for the client.
Choice D rationale
Attaching padding around the cannula tubing can help reduce the friction between the tubing and the skin, which can help prevent skin breakdown. This is the most appropriate action to take in this situation.

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Mark whether the statements by the new graduate nurse indicate understanding or no understanding of the use of the face mask in the care of this client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notices the presence of clear fluid on the surgical dressing of a patient who has just returned to the unit following lumbar spinal surgery. What immediate action should the nurse take?

Correct Answer is A

Explanation

The nurse notices redness under the chin of a client who is receiving oxygen at 2 L/minute via a nasal cannula. What action should the nurse take?

Correct Answer is D

Explanation

Restricted activity is prescribed for a client with Crohn’s disease. What is the primary purpose of the activity restriction?

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