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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 ["38"]

Explanation

Drop rate (gtt/min) = Volume to be infused (mL)/ Time of infusion (minutes) × Drop factor (gtt/mL)

Given:

Volume to be infused (V) = 75 mL Time of infusion (T) = 30 minutes Drop factor = 15 gtt/mL
Using the formula:

Drop rate (gtt/min)= [75/30]*15 Drop rate (gtt/min)=2.5×15

Drop rate (gtt/min)=37.5
Rounding to the nearest whole number, the nurse should regulate the IV to deliver approximately 38 gtt/minute.

A. Serum blood glucose level. B. Culture for sensitive organisms. C. C-reactive protein level. D. Blood pH level.

Correct Answer is B

Explanation

B. When purulent drainage is observed at a wound site, obtaining a culture of the drainage is essential for identifying the specific microorganisms causing the infection and determining their sensitivity to antibiotics.

A. Serum blood glucose level is not directly relevant to the assessment of purulent drainage at a wound site.

C. An elevated CRP level may indicate the presence of infection but obtaining a CRP level may not be as immediate or specific as obtaining a wound culture.

D. Blood pH level is not directly relevant to the assessment of purulent drainage at a wound site.

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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 healthcare provider prescribes an IV solution of clindamycin 850 mg in 75 mL of DW to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many glt/minute? (Enler numeric value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["38"]

Explanation

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

Which approach is best for the nurse to use when directing a client with Huntington's disease to the hospital cafeteria?

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

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

An adult client with multiple sclerosis (MS) fell while walking to the bathroom. On transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea, tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the lies of the tracheostomy tube, which action is most important for the nurse to take?

Patient Data Exhibits Mark whether the assessment findings indicate that the treatment was effective or ineffective. Assessment Findings

Patient Data

Exhibits

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