Nokea
A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? Select all.
- A. Family members who smoke must be at least 10 ft from the client when the oxygen is in use
- B. Nail polish should not be used near a client who is receiving oxygen
- C. A 'No smoking' sign should be placed on the front door
- D. Cotton bedding & clothing should be replaced with items made from wool
- E. A fire extinguisher should be readily available in the home
Correct Answer: B, C, E
Rationale: The correct answers are B, C, and E.
B: Nail polish should not be used near a client who is receiving oxygen to prevent a fire hazard as it is flammable.
C: A 'No smoking' sign should be placed on the front door to remind visitors not to smoke near the oxygen source.
E: A fire extinguisher should be readily available in the home to handle any fire emergencies related to oxygen use.
Incorrect choices:
A: Family members who smoke must be at least 10 ft from the client when the oxygen is in use is not as crucial as preventing ignition sources like nail polish.
D: Replacing cotton bedding & clothing with wool is unnecessary for oxygen safety.
You may also like to solve these questions
A nurse is caring for a client who is postoperative. Which of the following nursing interventions reduce the risk of thrombus development? Select all.
- A. Instruct the client not to use the Valsalva maneuver
- B. Apply elastic stockings
- C. Review lab values for total protein level
- D. Place pillows under the client's knees & lower extremities
- E. Assist the client to change position often
Correct Answer: B, E
Rationale: The correct answers are B and E. Applying elastic stockings helps promote circulation and prevent stasis, reducing the risk of thrombus formation. Assisting the client to change position often prevents prolonged immobility, which can lead to blood pooling and clot formation. Choice A is incorrect because the Valsalva maneuver can increase intra-abdominal pressure, potentially leading to venous stasis and thrombus formation. Choice C is irrelevant to thrombus prevention. Placing pillows under the client's knees and lower extremities (choice D) may promote comfort but does not directly reduce thrombus risk.
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? Select all.
- A. Apply the oxygen source loosely if the SPO2 decreases during the procedure
- B. Use surgical asepsis to remove & clean the inner cannula
- C. Clean the outer surfaces in a circular motion from the stoma site outward
- D. Replace the tracheostomy ties with new ties
- E. Cut a slit in gauze squares to place beneath the tube holder
Correct Answer: A, B, C
Rationale: The correct actions are A, B, and C. A) Applying the oxygen source loosely if the SPO2 decreases during the procedure ensures adequate oxygenation. B) Using surgical asepsis to remove and clean the inner cannula prevents infection. C) Cleaning the outer surfaces in a circular motion from the stoma site outward helps prevent contamination. Other options are incorrect because: D) Replacing the tracheostomy ties with new ties is not necessary each time. E) Cutting a slit in gauze squares is not a standard practice for tracheostomy care.
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding? Select all.
- A. Auscultate bowel sounds.
- B. Assist the client to an upright position.
- C. Test the pH of gastric aspirate.
- D. Warm the formula to body temperature.
- E. Discard any residual gastric contents.
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Auscultating bowel sounds is important to assess gastrointestinal motility and ensure the client is ready to receive the feeding.
B: Assisting the client to an upright position helps prevent aspiration during feeding by promoting proper tube placement.
C: Testing the pH of gastric aspirate confirms tube placement in the stomach and prevents potential complications from feeding into the lungs.
Summary:
D: Warming the formula is not necessary before administration and can lead to bacterial growth.
E: Discarding residual gastric contents should be done after assessing the pH, not before.
A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? Select all.
- A. Bradycardia
- B. Hypotension
- C. Fever
- D. Poor skin turgor
- E. Peripheral edema
Correct Answer: B, C, D
Rationale: The correct answers are B, C, and D. Diarrhea leads to fluid loss, causing hypotension (B) due to decreased blood volume, fever (C) as a result of dehydration and infection, and poor skin turgor (D) due to decreased tissue hydration. Bradycardia (A) is unlikely as the body compensates for dehydration with increased heart rate. Peripheral edema (E) is not expected as dehydration leads to fluid depletion, not retention.
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. Heat stroke is characterized by the body's inability to regulate its temperature due to prolonged exposure to high temperatures. This leads to excessive sweating and dehydration, resulting in a drop in blood pressure (hypotension). Bradycardia (B) is a slow heart rate, which is not typically seen in heat stroke. Clammy skin (C) is common in heat exhaustion, not heat stroke. Bradypnea (D) is slow breathing, which is not a common sign of heat stroke. Therefore, hypotension is the most appropriate choice as it aligns with the pathophysiology of heat stroke.