The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

Increase the liter flow of oxygen.

Encourage the client to take deep breaths.

Remove the mask to deflate the bag.

Document the assessment data.

Answer and Explanation

The Correct Answer is A

Choice A reason: If the oxygen reservoir bag of a partial rebreather mask does not deflate completely during inspiration, it may indicate that the flow rate is too low. Increasing the liter flow ensures adequate delivery of oxygen.

Choice B reason: Encouraging the client to take deep breaths is beneficial for overall respiratory function but will not address the issue of the reservoir bag not deflating properly.

Choice C reason: Removing the mask to deflate the bag is not a standard practice and could interrupt the delivery of oxygen to the client.

Choice D reason: Documentation of the assessment data is important, but the nurse must first address the issue with the oxygen delivery system to ensure the client is receiving the proper amount of oxygen.

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Correct Answer is B

Explanation

Choice A reason: While unpleasant odor can indicate poor oral hygiene or other health issues, it is not as urgent as some other findings.

Choice B reason: White patches on the mucosa can indicate an infection such as oral thrush, which requires medical treatment, making it the most important finding to act upon.

Choice C reason: A receding gumline is a concern for dental health but does not typically require immediate action.

Choice D reason: Discoloration of teeth can indicate various issues, including dietary habits or decay, but is not as immediately concerning as white patches on the mucosa. Bolded text indicates the correct answers and important information.

A. Using two or three people increases client safety. B. The technique is intended to maintain straight spinal alignment. C. Turning instead of pulling reduces the likelihood of skin damage. D. Working together can decrease the risk of back injury to the nurses.

Correct Answer is B

Explanation

Choice A reason: While using multiple people can increase safety, it is not the primary purpose of the log rolling technique.

Choice B reason: The log rolling technique is specifically designed to maintain straight spinal alignment, especially in patients with suspected spinal injuries, to prevent further injury.

Choice C reason: Reducing skin damage is a benefit of proper patient handling, but it is not the main reason for using the log rolling technique.

Choice D reason: Decreasing the risk of back injury to nurses is important, but the primary purpose of the log rolling technique is to protect the patient's spinal integrity.

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The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?

Correct Answer is B

Explanation

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

Correct Answer is B

Explanation

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