The nurse is preparing to set up the oxygen administration and apply the simple face mask. What should the nurse do before applying the face mask? Select all that apply.
Determine if the client needs to go to the bathroom.
Identify the client using 2 client identifiers.
Perform hand hygiene.
Brush the client's teeth.
Don gloves.
Check the skin around the face.
Assess respiratory function.
Correct Answer : B,C,E,F,G
The correct answer is choice b. Identify the client using 2 client identifiers, c. Perform hand hygiene, e. Don gloves, f. Check the skin around the face, and g. Assess respiratory function.
Choice A rationale:
Determining if the client needs to go to the bathroom is not directly related to the immediate preparation for oxygen administration. However, it can be considered as part of overall patient comfort and care.
Choice B rationale:
Identifying the client using 2 client identifiers is crucial to ensure the correct patient is receiving the correct treatment, which is a standard safety protocol in healthcare settings.
Choice C rationale:
Performing hand hygiene is essential to prevent the spread of infection and maintain a sterile environment.
Choice D rationale:
Brushing the client’s teeth is not a necessary step before applying a simple face mask for oxygen administration. It is more related to general oral hygiene.
Choice E rationale:
Donning gloves is important to protect both the nurse and the patient from potential contamination and infection.
Choice F rationale:
Checking the skin around the face is important to ensure there are no existing sores or irritations that could be exacerbated by the mask.
Choice G rationale:
Assessing respiratory function is critical to determine the patient’s baseline respiratory status and to monitor the effectiveness of the oxygen therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale for Choice A:
Serum Helicobacter pylori (H. pylori) antibody results are not directly relevant to the diagnosis or management of acute pancreatitis. While H. pylori infection can cause gastritis and peptic ulcers, it is not a common cause of pancreatitis.
Urine output amounts are important to monitor in patients with pancreatitis to assess for dehydration and kidney function. However, they are not as specific to the diagnosis of pancreatitis as other findings.
Rationale for Choice B:
Reports of chronic constipation are not typically associated with acute pancreatitis.
Serum gastrin levels are used to diagnose conditions such as Zollinger-Ellison syndrome, which is characterized by excessive acid production in the stomach. They are not relevant to the diagnosis of pancreatitis.
Rationale for Choice C:
Severity of nausea and vomiting are key symptoms of pancreatitis. The severity of these symptoms can help to gauge the severity of the pancreatitis and guide treatment decisions.
Serum amylase results are a highly sensitive and specific marker for pancreatitis. Elevated levels of amylase in the blood strongly suggest the presence of pancreatitis.
Rationale for Choice D:
Presence of bowel sounds can be variable in patients with pancreatitis and are not always reliable indicators of the severity of the condition.
Degree of abdominal pain is a subjective symptom that can be difficult to assess accurately. While it is an important symptom of pancreatitis, it is not as objective as other findings such as serum amylase levels.
Therefore, the most valuable information to report to the healthcare provider in this case is the severity of nausea and vomiting and serum amylase results.
Correct Answer is B
Explanation
Choice A rationale:
While teaching the client about infection prevention measures is important, it is not the most crucial action in this situation. The client is already exhibiting symptoms and has potentially been spreading the virus.
Focusing on isolation at this point is a more effective way to prevent further transmission.
Additionally, the client may be too ill to fully comprehend or adhere to instructions regarding masks, handwashing, and social distancing.
Choice B rationale:
Isolation is the most essential action to prevent the spread of COVID-19 to others. This is because:
COVID-19 is highly contagious and can spread through respiratory droplets produced when an infected person coughs, sneezes, or talks.
Isolation physically separates the infected person from others, reducing the risk of transmission.
Proper PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the infectious droplets, further minimizing the risk of spread.
Choice C rationale:
Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus. However, it is not as immediate a priority as isolating the client to prevent further transmission.
Choice D rationale:
Counseling family members about monitoring for symptoms is also important for early identification and containment of potential cases. However, it does not directly address the immediate risk of transmission from the actively symptomatic client.
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