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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.

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Correct Answer is C

Explanation

C. Type I hypersensitivity reactions, also known as immediate hypersensitivity reactions, involve the production of IgE antibodies in response to an allergen. In this case, the bee sting likely triggered an IgE-mediated immune response, leading to the release of inflammatory mediators such as histamine. The client's symptoms of body rash, shortness of breath, tachycardia, and hypotension are characteristic of anaphylaxis, which is a severe and potentially life-threatening manifestation of Type I hypersensitivity reactions.

A.. Type II hypersensitivity reactions occur when the immune system targets antigens on the body's own cells, leading to cell destruction or dysfunction.

B. Autoimmune responses involve the immune system mistakenly attacking the body's own tissues and organs, leading to inflammation and tissue damage.

D. Cell-mediated hypersensitivity reactions involve the activation of T cells and the release of cytokines, resulting in inflammation and tissue damage. Examples include delayed-type hypersensitivity reactions such as contact dermatitis or tuberculin skin testing reactions.

A. "I should use this medication in its handihaler every day." B. "I will use my other inhaler in between uses." C. "When I cough up sputum, the secretions should be less thick." D. "If I have sudden shortness of breath, I will use this inhaler."

Correct Answer is A

Explanation

A. Tiotropium is commonly delivered via a handihaler device for inhalation. Using the medication every day is consistent with the recommended dosing regimen for managing chronic obstructive pulmonary disease (COPD) symptoms.

B. While it's important for clients with COPD to have access to a rescue inhaler for sudden shortness of breath, it's also crucial for them to understand the specific instructions for using each medication.

C. Tiotropium is a long-acting bronchodilator that helps relax the airway muscles. It does not have direct effect on the thickness of mucus secretions.

D. While tiotropium can help prevent exacerbations and reduce the frequency of sudden shortness of breath, it is not typically used as a rescue inhaler for acute symptom relief.

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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 diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates that the client understands the instructions for using this medication?

Correct Answer is A

Explanation

A client with emphysema reports difficulty breathing and exhibits audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants Immediate intervention by the nurse?

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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?

Patient Data

Exhibits

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