NUR 518 Clinical Essentials Questions And Answers Rated A+ 2024 Guaranteed Tests
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Course
NUR 518
Institution
NUR 518
NUR 518 Clinical Essentials Questions And Answers Rated A+ 2024 Guaranteed Tests
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 cont...
NUR 518 Clinical Essentials Questions And Answers
Rated A+ 2024 Guaranteed Tests
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. 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. 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 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 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 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. 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 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.
Before performing a wound assessment, which nursing action would reduce the patient's risk for infection?
A. Taking the patient's temperature
B. Applying clean gloves
C. Assessing the wound for drainage
D. Assessing the dressing for drainage ANS B. Applying clean gloves
Rationale: Wearing clean gloves would reduce the risk for infection when removing an old dressing. Measuring the
patient's temperature could identify an infection but would not reduce the patient's risk for infection. Assessing the
wound and dressing for drainage would not affect the patient's risk for infection.
, Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a
wound?
A. Assessing the site for signs of redness or swelling
B. Reporting the presence of wound odor
C. Removing a soiled outer dressing
D. Opening sterile dressings during the dressing change ANS B. Reporting the presence of wound odor
Rationale: The task of reporting the presence of odor in the area of the wound may be delegated to NAP. Wound
assessment may not be delegated to NAP. NAP are not permitted to remove a wound dressing or to participate in
setting up a sterile field.
The nurse notes that a patient's surgical wound is healing slowly. Which health problem would contribute to slow
wound healing?
A. Osteoarthritis
B. Glaucoma
C. Deafness
D. Diabetes mellitus ANS D. Diabetes mellitus
Rationale: Diabetes decreases tissue perfusion, impairing the supply of oxygen to the tissues. This slows wound
healing. Osteoarthritis, glaucoma, and being hearing impaired do not contribute to slow wound healing.
A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could
initiate at the next dressing change in order to reduce the patient's pain?
A. Premedicate the patient with a prescribed analgesic 30 minutes before the intervention.
B. Use a distraction technique to divert the patient's attention during the procedure.
C. Position the patient comfortably before the intervention.
D. Thoroughly explain the procedure to the patient. ANS A. Premedicate the patient with a prescribed analgesic
30 minutes before the intervention.
Which action reduces the nurse's risk for infection when changing the dressing of an infected abdominal wound?
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