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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 C

Explanation

C. The client's weak cough effort and use of accessory muscles to breathe suggest the presence of retained respiratory secretions, which can impair breathing and lead to further respiratory compromise. Suctioning to clear secretions from the airway can help improve air exchange and alleviate respiratory distress.

A. The client's primary issue appears to be respiratory distress rather than fever.

B. Offering pain relief is important for overall comfort but it is not be the most immediate intervention needed to address the client's respiratory distress.

D. Arterial blood gases may provide valuable information but they may not be the most immediate intervention needed to address the client's respiratory distress.

A. Hematemesis B. Brown, foarmy urine. C. Clay-colored stool. D. Anorexia.

Correct Answer is A

Explanation

A Hematemesis refers to vomiting blood, which can occur when esophageal varices rupture and bleed into the gastrointestinal tract. It is a hallmark sign of upper gastrointestinal bleeding and requires immediate medical attention. Monitoring for hematemesis allows for early detection of variceal bleeding and prompt intervention to prevent further complications.

B Brown, foamy urine may indicate the presence of blood or protein in the urine, which can occur in various kidney and urinary tract disorders.

C Clay-colored stool may indicate a lack of bile in the stool, which can occur in conditions affecting the liver or bile ducts, such as obstructive jaundice.

D Anorexia, or loss of appetite, is a common symptom in clients with chronic liver disease, including cirrhosis. However, while anorexia may impact nutritional status and overall health, it is not directly related to the complications of esophageal varices.

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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

Correct Answer is C

Explanation

A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

Correct Answer is A

Explanation

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Patient Data

Exhibits

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