NUR 518 Clinical Essentials Latest
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,1. When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to
help maintain good skin integrity?
A. Frequently applying moisturizing lotion to facial areas that come into contact with the cannula.
B. Removing the cannula every 2 hours for no longer than 10 minutes.
C. Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift.
D. Instructing the patient to inform staff of any problems with facial dryness or cracking. - correct ans:C.
Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift.
Rationale: Frequent assessment is a priority and will help the nurse identify early signs of skin
breakdown. Although applying lotion is appropriate, this option is not the best way to maintain good
skin integrity. It may not be appropriate to remove the cannula in a patient for whom oxygen therapy
has been ordered. The patient may be unaware of facial skin areas that are dry or cracking.
2. When caring for a patient who is receiving oxygen by simple face mask, which action ensures that the
rate of oxygen being delivered is appropriate?
A. Frequently asking the patient how he or she is breathing.
B. Ensuring that the oxygen tubing is pulled tight, with little or no slack.
C. Securing the oxygen tubing to the patient's clothing to prevent tugging.
D. Assessing for proper placement of the mask on the patient's face. - correct ans:D. Assessing for
proper placement of the mask on the patient's face.
Rationale: Monitoring placement of the cannula tips helps ensure that the patient receives the oxygen
prescribed. Asking the patient if he or she is having trouble breathing does not address oxygen delivery.
Oxygen tubing should not be pulled tight. There should be enough slack in the tubing to allow the
patient to turn his or her head comfortably. Securing the oxygen tubing to keep the patient from pulling
out the cannula does not address oxygen delivery.
When caring for a patient for whom oxygen by nonrebreathing mask has been ordered, which action
ensures appropriate oxygen delivery?
A. Looping the oxygen tubing around the side rail of the bed
,B. Assessing breath sounds every shift
C. Securing the tubing snugly to the patient's gown
D. Assessing that the reservoir bag stays inflated - correct ans:D. Assessing that the reservoir bag stays
inflated
Rationale: A mask that fits properly will deliver the prescribed amount of oxygen. The oxygen tubing
should not be looped around the side rail of the bed. Assessing breath sounds does not ensure that the
oxygen is being delivered appropriately. The tubing should have some slack so that the patient can move
his or her head.
When caring for a patient who is receiving supplemental oxygen by face tent, which action ensures that
the oxygen is flowing?
A. Testing the closing capacity of the mask's valves
B. Routinely monitoring the seal over the patient's mouth and nose
C. Ensuring that a mist is always present
D. Regularly verifying that the mask is positioned loosely - correct ans:C. Ensuring that a mist is always
present
Rationale: It is appropriate to ensure that a mist is always present when oxygen is delivered by face tent.
Testing the closing capacity of the mask's valves is appropriate only for a nonrebreathing mask.
Monitoring the seal over the patient's mouth and nose is appropriate only for a nonrebreathing mask.
Such an assessment is appropriate, but correct positioning of the mask does not indicate that oxygen is
flowing from it.
What would the nurse do when receiving an order to increase the delivery rate of a patient's oxygen per
nasal cannula from 1 L/min to 3 L/min?
A. Encourage the patient to take deeper breaths in order to get more oxygen
B. Change the device from nasal cannula to simple face mask
C. Ensure that humidification is present
D. Adjust the float ball on the flow meter to 3 L/min - correct ans:D. Adjust the float ball on the flow
meter to 3 L/min
, Rationale: The nurse would increase the flow rate by moving the ball on the oxygen delivery system
from 1 L/min to 3 L/min. Taking deeper breaths will not change the flow rate from 1 L/min to 3 L/min.
There is no need to change the delivery device. The provider has ordered oxygen to be administered per
nasal cannula, not per simple face mask. If the flow rate of oxygen is 4 L/min or higher, humidification is
added. Oxygen delivered at the rate of 3 L/min need not be humidified.
A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the
nurse's responsibility in assessing this patient's wound?
A. Remove the dressing, inspect the wound, and reapply a new dressing.
B. Inspect the wound and reapply the surgical dressing every 2 hours.
C. Inspect the wound, and keep the dressing off until the health care provider arrives.
D. Wait until the health care provider orders the removal of the surgical dressing. - correct ans:D. Wait
until the health care provider orders the removal of the surgical dressing.
Rationale: The nurse would want to wait until the provider orders the dressing to be removed to ensure
that the initial dressing is ready to come off. The nurse would not remove an initial surgical dressing for
direct wound inspection until the health care provider has written an order for its removal.
Which wound would be allowed to heal by secondary intention?
A. Cleft lip repair
B. Infected hysterectomy incision
C. Exploratory laparoscopy incision
D. Facial laceration caused by a pocket knife - correct ans:B. Infected hysterectomy incision
Rationale: The infected hysterectomy incision would heal by secondary intention because it is an
infected surgical wound. The cleft lip repair and the exploratory laparoscopy incision would heal by
primary intention because they were created during a surgical procedure. The facial laceration caused
by a pocket knife would heal by primary intention, since there is no tissue loss.
Verified Version And Frequently tested
Exam With Expected real Questions
With Well Elaborated Correct Answers
GRADED A+
Professional Academic Assistance Services
Services Offered
Proctored Exam Assistance
Online Class Management (Full Course Support)
Exam Preparation & Study Materials
Assignments and Coursework Support
Essays and Research Papers
Discussion Posts and Replies
,1. When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to
help maintain good skin integrity?
A. Frequently applying moisturizing lotion to facial areas that come into contact with the cannula.
B. Removing the cannula every 2 hours for no longer than 10 minutes.
C. Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift.
D. Instructing the patient to inform staff of any problems with facial dryness or cracking. - correct ans:C.
Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift.
Rationale: Frequent assessment is a priority and will help the nurse identify early signs of skin
breakdown. Although applying lotion is appropriate, this option is not the best way to maintain good
skin integrity. It may not be appropriate to remove the cannula in a patient for whom oxygen therapy
has been ordered. The patient may be unaware of facial skin areas that are dry or cracking.
2. When caring for a patient who is receiving oxygen by simple face mask, which action ensures that the
rate of oxygen being delivered is appropriate?
A. Frequently asking the patient how he or she is breathing.
B. Ensuring that the oxygen tubing is pulled tight, with little or no slack.
C. Securing the oxygen tubing to the patient's clothing to prevent tugging.
D. Assessing for proper placement of the mask on the patient's face. - correct ans:D. Assessing for
proper placement of the mask on the patient's face.
Rationale: Monitoring placement of the cannula tips helps ensure that the patient receives the oxygen
prescribed. Asking the patient if he or she is having trouble breathing does not address oxygen delivery.
Oxygen tubing should not be pulled tight. There should be enough slack in the tubing to allow the
patient to turn his or her head comfortably. Securing the oxygen tubing to keep the patient from pulling
out the cannula does not address oxygen delivery.
When caring for a patient for whom oxygen by nonrebreathing mask has been ordered, which action
ensures appropriate oxygen delivery?
A. Looping the oxygen tubing around the side rail of the bed
,B. Assessing breath sounds every shift
C. Securing the tubing snugly to the patient's gown
D. Assessing that the reservoir bag stays inflated - correct ans:D. Assessing that the reservoir bag stays
inflated
Rationale: A mask that fits properly will deliver the prescribed amount of oxygen. The oxygen tubing
should not be looped around the side rail of the bed. Assessing breath sounds does not ensure that the
oxygen is being delivered appropriately. The tubing should have some slack so that the patient can move
his or her head.
When caring for a patient who is receiving supplemental oxygen by face tent, which action ensures that
the oxygen is flowing?
A. Testing the closing capacity of the mask's valves
B. Routinely monitoring the seal over the patient's mouth and nose
C. Ensuring that a mist is always present
D. Regularly verifying that the mask is positioned loosely - correct ans:C. Ensuring that a mist is always
present
Rationale: It is appropriate to ensure that a mist is always present when oxygen is delivered by face tent.
Testing the closing capacity of the mask's valves is appropriate only for a nonrebreathing mask.
Monitoring the seal over the patient's mouth and nose is appropriate only for a nonrebreathing mask.
Such an assessment is appropriate, but correct positioning of the mask does not indicate that oxygen is
flowing from it.
What would the nurse do when receiving an order to increase the delivery rate of a patient's oxygen per
nasal cannula from 1 L/min to 3 L/min?
A. Encourage the patient to take deeper breaths in order to get more oxygen
B. Change the device from nasal cannula to simple face mask
C. Ensure that humidification is present
D. Adjust the float ball on the flow meter to 3 L/min - correct ans:D. Adjust the float ball on the flow
meter to 3 L/min
, Rationale: The nurse would increase the flow rate by moving the ball on the oxygen delivery system
from 1 L/min to 3 L/min. Taking deeper breaths will not change the flow rate from 1 L/min to 3 L/min.
There is no need to change the delivery device. The provider has ordered oxygen to be administered per
nasal cannula, not per simple face mask. If the flow rate of oxygen is 4 L/min or higher, humidification is
added. Oxygen delivered at the rate of 3 L/min need not be humidified.
A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the
nurse's responsibility in assessing this patient's wound?
A. Remove the dressing, inspect the wound, and reapply a new dressing.
B. Inspect the wound and reapply the surgical dressing every 2 hours.
C. Inspect the wound, and keep the dressing off until the health care provider arrives.
D. Wait until the health care provider orders the removal of the surgical dressing. - correct ans:D. Wait
until the health care provider orders the removal of the surgical dressing.
Rationale: The nurse would want to wait until the provider orders the dressing to be removed to ensure
that the initial dressing is ready to come off. The nurse would not remove an initial surgical dressing for
direct wound inspection until the health care provider has written an order for its removal.
Which wound would be allowed to heal by secondary intention?
A. Cleft lip repair
B. Infected hysterectomy incision
C. Exploratory laparoscopy incision
D. Facial laceration caused by a pocket knife - correct ans:B. Infected hysterectomy incision
Rationale: The infected hysterectomy incision would heal by secondary intention because it is an
infected surgical wound. The cleft lip repair and the exploratory laparoscopy incision would heal by
primary intention because they were created during a surgical procedure. The facial laceration caused
by a pocket knife would heal by primary intention, since there is no tissue loss.
