Nokea
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?
- A. The client uses a wool blanket on their bed.
- B. The client identifies the location of the fire extinguisher.
- C. The client stores an oxygen tank in a secure outdoor shed.
- D. The client has a weekly inspection checklist for oxygen equipment.
Correct Answer: D
Rationale: The correct answer is D because a weekly inspection checklist for oxygen equipment ensures that the equipment is functioning properly and reduces the risk of potential hazards. Option A is incorrect because wool blankets can create static electricity, which is a fire hazard. Option B is not directly related to oxygen safety. Option C is incorrect as storing an oxygen tank in an outdoor shed may expose it to extreme temperatures or moisture.
You may also like to solve these questions
The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
- E. Wear a sterile water-resistant gown if within 3 feet of the client.
Correct Answer: A, B, C, E
Rationale: The correct interventions for placing a client on isolation precautions include A, B, C, and E. A) Wearing an N95 mask is crucial for airborne precautions. B) Placing a container for soiled linens inside the room prevents contamination. C) A negative airflow room helps contain airborne pathogens. E) Wearing a sterile water-resistant gown within close proximity to the client prevents transmission. D is incorrect as the mask should be removed inside the client's room. Choices F and G are likely blank options or not relevant to isolation precautions.
A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?
- A. Document the provider's statement in the medical record.
- B. Consult the facility's risk manager.
- C. Complete an incident report.
- D. Notify the nursing manager.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse should document the provider's statement in the medical record. This is important for legal and communication purposes. By documenting the surgeon's instructions, the nurse ensures that the care provided is well-documented and can be tracked for continuity of care. It also serves as evidence that the nurse followed the provider's orders appropriately.
Summary:
B: Consulting the facility's risk manager is not necessary at this point as the situation does not involve a risk management issue.
C: Completing an incident report is not warranted as there is no indication of an incident or error that has occurred.
D: Notifying the nursing manager is not the immediate action required in this situation. The nurse should prioritize following the provider's instructions and documenting the communication.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
- A. Position the client at the head of the bed elevated to 30° prior to insertion of the NG tube.
- B. Remove the NG tube if the client begins to gag or choke.
- C. Apply suction to the NG tube prior to insertion.
- D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Having the client take sips of water serves to promote the insertion of the NG tube into the esophagus by facilitating swallowing and opening the esophageal sphincter, making it easier to pass the tube through. This action helps ensure proper placement of the tube in the stomach without risking insertion into the trachea or lungs.
Summary of other choices:
A: Positioning the client at the head of the bed elevated to 30° is important but is not directly related to the insertion of the NG tube.
B: Removing the NG tube if the client gags or chokes is incorrect as these are common responses during insertion, and removing the tube may lead to premature discontinuation.
C: Applying suction to the NG tube prior to insertion is unnecessary and may cause discomfort or damage to the mucosa.
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Pad the client's wrist before applying the restraints.
- B. Evaluate the client's circulation every 8 hr after application.
- C. Remove the restraints every 4 hr to evaluate the client's status.
- D. Secure the restraint ties to the bed's side rails.
Correct Answer: A
Rationale: The correct answer is A: Pad the client's wrist before applying the restraints. This is important to prevent pressure injuries and ensure the client's comfort and safety. Padding helps distribute pressure and reduces the risk of skin breakdown. Choices B, C, and D are incorrect. B is not recommended as it is essential to monitor circulation frequently, not just every 8 hours. C is incorrect because restraints should not be removed without a valid reason due to the risk of injury or harm to the client. D is also wrong as restraints should be secured to parts of the bed frame, not side rails, to prevent the client from using them to injure themselves or others.
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
- A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
- B. Regulate oxygen via nasal cannula at flow rate of no more than 6 L/min.
- C. Make sure the reservoir bag of a partial rebreathing mask remains deflated.
- D. Use petroleum jelly to lubricate the client's nares face and lips.
Correct Answer: B
Rationale: The correct answer is B: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. This is the appropriate action for administering oxygen therapy to prevent oxygen toxicity. Oxygen should be delivered at the lowest effective flow rate to minimize the risk of complications. Choices A, C, and D are incorrect. A is incorrect because the flow rate should be aligned with the bottom of the ball in the flow meter, not the top. C is incorrect because the reservoir bag of a partial rebreathing mask should be inflated to ensure adequate oxygen delivery. D is incorrect because petroleum jelly should not be used in oxygen therapy due to the risk of fire hazard.