•NEW GENERATION 2024 HESI EXIT NURSING COMPREHENSIVE EXAN LATEST UPDATE WITH CORRECT SOLUTION GRADED A+
•A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first?
A. A client who has heart failure and is receiv...
NEW GENERATION 2024 HESI EXIT
•
NURSING COMPREHENSIVE EXAN LATEST
UPDATE WITH CORRECT SOLUTION
GRADED A+
• A nurse is planning care for a group of clients receiving oxygen therapy.
Which of the following clients should the nurse plan to see first?
A.A client who has heart failure and is receiving 100% oxygen via partial
rebreather mask
-The nurse should apply the safety and risk-reduction priority-setting framework,
which assigns priority to the factor or situation posing the greatest safety risk to
the client. When there are several risks to client safety, the one posing the greatest
threat is the highest priority. The nurse should use Maslow’s hierarchy of needs,
the ABC priority-setting framework, and/or nursing knowledge to identify which
risk poses the greatest threat to the client.
-The nurse should frequently check the bag on a rebreather mask to ensure it
inflates properly. If the bag is deflated, the client will rebreathe exhaled carbon
dioxide instead of receiving the prescribed oxygen dose. Therefore, the nurse
should first see the client who that can cause toxicity and is highly combustible,
and higher concentrations of oxygen increase the risk of client injury.
B.A client who has emphysema and is receiving oxygen at 3L/min via
transtracheal oxygen cannula
-incorrect: Routine treatment for chronic lung conditions can include the use of a
transtracheal oxygen cannula; therefore, there is another client the nurse should
plan to see first. The client will learn to use the device alone, and the system can
provide adequate oxygenation with a low flow rate of oxygen. Three liters per
,minute of oxygen is the equivalent of 32% oxygen delivery.
C.A client who has an old tracheostomy and is receiving 40%
,humidified oxygen via tracheostomy collar
-incorrect: Routine treatment for a client who has an old tracheostomy includes
the administration of humidified oxygen or air via tracheostomy collar.
Therefore, there is another client the nurse should plan to see first. The nurse
should sue the humidification to promote
, loosening of respiratory secretions and prevent cannula obstruction. Forty percent
oxygen is the equivalent of administering oxygen at 6L/min.
D.A client who has COPD and is receiving oxygen at 2L/min via nasal cannula
-incorrect: Routine treatment for a client who has COPD involves the
administration of low-dose therapy. Therefore, there is another client the nurse
should plan to see first. Clients who have COPD depend on low oxygen level to
drive their respiratory rate. Two liters per minute of oxygen is the equivalent of
28% oxygen delivery.
• A nurse is assisting a client who is eating at mealtime. Suddenly, the client
grabs her neck with both hands and appears frightened. Which of the following
actions should the nurse take first?
A.Place an oxygen mask on the client
B.Check the client’s pulses
C.Determine whether the client is able to breathe
-Caring for this client requires the application of the nursing process priority-
setting framework. The nurse can use the nursing process to plan client care and
prioritize nursing actions. Each step of the nursing process builds on the previous
step, beginning with an assessment or data collection. Before the nurse can
formulate a plan of action, implement a nursing intervention, or notify a provider
of a change in the client’s status, the nurse must first collect adequate data from the
client. Assessing or collecting additional data will provide the nurse with the
knowledge needed to make an appropriate decision.
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