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Patient Data

Exhibits

What should the nurse do before applying the face mask? Select that apply.

Perform hand hygiene

Identify the client using Z client identifiers

Determine if the client needs to go to the bathroom

Check the skin around the face

Don gloves

Brush the client's teeth

Assess respiratory function

Answer and Explanation

Correct Answer : A,B,D,E,G

A. Hand hygiene is essential to prevent the transmission of microorganisms and maintain infection control standards.
B. Verifying the client's identity using two unique identifiers, such as name and date of birth, helps prevent errors and ensures that the intervention is performed on the correct individual.
D. Assessing the skin around the face helps identify any abnormalities, irritation, or contraindications to applying the face mask, such as open wounds or dermatitis.
E. Wearing gloves helps prevent the transmission of microorganisms and protects both the nurse and the client during the application of the face mask.
G. Assessing respiratory function helps determine the client's need for the face mask and ensures that it is applied appropriately based on the client's respiratory status and needs.
C. While it's important to address the client's toileting needs, determining whether the client needs to go to the bathroom is not directly related to the application of a face mask unless there are specific concerns about the client's comfort or ability to tolerate the mask.
F. Brushing the client's teeth is not typically performed before applying a face mask unless there are specific clinical indications or the client requests oral care. However, oral care may be performed as part of routine hygiene practices or if the client is intubated and oral hygiene is necessary.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A Preventing esophageal reflux is essential in managing symptoms associated with a direct hiatal hernia. Nursing interventions may include promoting proper positioning (elevating the head of the bed), encouraging smaller, more frequent meals, avoiding trigger foods, and administering medications as prescribed to reduce acid reflux.

B Promoting intestinal peristalsis may be beneficial in certain gastrointestinal conditions, such as constipation but it is not directly related to the management of a direct hiatal hernia.

C Promoting effective swallowing is important for overall swallowing function and preventing aspiration in some cases, it may not directly address the symptoms or complications associated with a direct hiatal hernia.

D Maintaining intact oral mucosa is important for oral health and preventing complications such as oral mucositis, but it is not directly related to the management of a direct hiatal hernia.

A. Avoid treating fever with antipyretics B. Encourage the client to take breaks from the oxygen mask every few hours C. Providing suctioning so the client does not have to cough D. Assist the client in ambulating safely E. Asking the client do quick, shallow breaths F. Positioning the client with the head of the bed elevated G. Teaching the client to cough at least once an hour

Correct Answer is ["B","D","F"]

Explanation

B. Encourage the client to take breaks from the oxygen mask every few hours: While supplemental oxygen may be necessary for clients with pneumonia who are hypoxemic, encouraging periodic breaks from the oxygen mask allows the client to mobilize and promote lung expansion, which can improve ventilation and oxygenation.

D. Ambulation helps prevent complications such as pneumonia-associated atelectasis by promoting lung expansion and mobilizing respiratory secretions. However, it's essential to ensure that ambulation is safe and appropriate based on the client's condition and mobility status.

F. Elevating the head of the bed promotes optimal lung expansion, reduces the work of breathing, and helps improve oxygenation in clients with pneumonia. This position also facilitates drainage of respiratory secretions and decreases the risk of aspiration.

A. Fever is often a sign of infection and can increase metabolic demand and oxygen consumption. Treating fever with antipyretics helps reduce metabolic demand, discomfort, and respiratory distress, thereby potentially improving ventilation and oxygenation.

C. Suctioning may be necessary to remove respiratory secretions in clients with pneumonia who are unable to clear their airways effectively. However, routine suctioning should be avoided unless clinically indicated, as it may cause discomfort and irritation to the airways.

E. Quick, shallow breaths (hyperventilation) can lead to respiratory alkalosis and impair oxygenation. Instead, clients with pneumonia should be encouraged to breathe slowly and deeply to promote effective gas exchange and lung expansion.

G. Teaching the client to cough at least once an hour: While coughing can help clear respiratory secretions and improve ventilation in clients with pneumonia, coughing excessively or unnecessarily may cause fatigue and discomfort. Clients should be encouraged to cough as needed to clear secretions but not excessively.

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Patient Data Exhibits What should the nurse do before applying the face mask? Select that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

Correct Answer is A

Explanation

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

Correct Answer is ["B","D","F"]

Explanation

The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety and a hoarse voice. Which nursing problem is the priority for this client?

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The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

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

Patient Data

Exhibits

What should the nurse do before applying the face mask? Select that apply.